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Outcome of Transduo denal Surgical Ampullectomy for Ampullary Neopla는
( Yang Won Nah ),( Hyung Woo Park ),( Byeung Ju Kang ),( Byung Wook Lee ),( Sung Jo Bang ),( Hye Jung Choi ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Purpose: Adenomas arising from the ampulla of Vater (AoV) are premalignant lesions with risk for malignant transformation to carcinoma following the adenoma-to-carcinoma sequence. Accordingly, many experts advocate resection either endoscopically or surgically. However, excluding associated malignant disease prior to resection of an adenoma of the AoV is not always possible. And the procedure of choice to treat this rare tumor is still controversial among endoscopic papillectomy (EP), transduodenal surgical ampullectomy (TSA) and pancreatoduodenectomy (PD). With the introduction of EP recent years, TSA was regarded as a tool for unsuitable lesion for EP or after unsuccessful EP by some. In addition to this there might be a role of TSA for preinvasive early stage adenocarcinoma of AoV, substituting PD. This study was done to evaluate the outcomes of transduodenal surgical ampullectomy (TSA) of ampulla of Vater (AoV) neoplasm including adenoma as well as adenocarcinoma limited to the ampulla. Methods: 22 cases of AoV neoplasm treated by transduodenal surgical ampullectomy (TSA) during the period from 2010 to 2015 were reviewed retrospectively. Results: The patients were aged from 36 to 81 years (mean 56) and 12 were male. 11 patients were identified during routine health screening. The most frequent symptom was indigestion and noted in 4. Cholangitis and liver abscess was the initial presentation in one case each. Two cases were associated with familial adenomatous polyposis syndrome (FAP). Seven cases of TSA were performed after endoscopic papillectomy for unsuitability (2), inadequacy (2) or tumor recurrence (3). Preoperative endoscopic biopsy revealed adenoma in 11, low grade dysplasia (LGD) in 4, high grade dysplasia (HGD) in 5 and neuroendocrine tumor in 1. No case was diagnosed as adenocarcinoma on preoperative biopsy. Intraoperative frozen biopsy was done in 14 cases and revealed adenocarcinoma in 4 which were corresponding to adenoma in 2, LGD in 1 and HGD in 1 on preoperative biopsy. Two patients were converted to pylorus preserving PD according to the frozen biopsy result. Of TSA, 100 per cent had clear margins grossly and microscopically. Postoperative pathology revealed adenocarcinoma in 7 cases. All the adenocarcinomas were in their very early stage, reflected by carcinoma in situ in 2, invasion to lamina propria in 2, confined to mucosa in 1, confined to ampulla of Vater in 1 and focal adenocarcinoma of 2mm. There was no case of lymphovascular or perineural invasion. And those 2 cases who underwent PPPD revealed no lymph node metastasis. 5 patients with adenocarcinoma who underwent TSA showed no evidence of recurrence during follow period from 22 to 58 months. And all the 13 patients with adenoma, either with or without HGD showed no evidence of recurrence for 2 to 69 months. There were 3 complications after TSA including wound seroma in 1, voiding difficulty in 1 and T inversion on EKG in 1. Conclusion: Transduodenal surgical ampullectomy can be done safely with minimal morbidity while securing adequate safety margin for ampullary neoplasm. When the preoperative biopsy result of ampullary neoplasm does not tell adenocarcinoma definitely, TSA would be a good substitute for PD even though preoperative biopsy was not always correct in detecting adenocarcinoma. More study to define the detailed indication of TSA for adenocarcinoma of AoV is needed.