Tumores Ampulares

Dr. Alberto EspinoDpto Gastroenterologia UC

Sept 02, 2014

Es importante examinar la papila?

• Es recomendado visualizar la segunda porción duodenal incluyendo la papila mayor en toda EDA estándard

• Detección precoz de enfermedades periampulares y enfermedades pancreatobiliares.

• Factores de dificultad:– Características anatomicas de D2– Angulo tangencial– Divertículo periampular– Formación de loop

WJG 2013;19: 2037-2043GIE 2012; 75: 254-260

¿Cómo es una papila normal?

¿Cuántos de ustedes examinan la papila duodenal durante una EDA ?

Examen de ampolla de Vater o papila mayorCompleto, incompleto y no visualizada

WJG 2013

Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found.

Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s.

There were no complications and no significant mucosal trauma.

Periampullary Tumours• Relatively rare– Annual incidence of 3000 cases in US1

– prevalence rates estimated to be 0.04 to 0.12 % in autopsy series

• 95% adenomas (villous and tubulovillous)– 5% neuroendocrine tumours, paragangliomas etc

• Occur sporadically or more commonly in the setting of FAP (80% lifetime incidence, 4% risk of malignancy)

• Stepwise progression to adenocarcinoma– 25 - 80% for sporadic adenomas2

1. Martin Gastro Intest Clin N A 2003 2. Burke GIE 1999

• Clinical features– Asymptomatic – particularly in FAP undergoing

surveillance– Jaundice, fluctuating LFT’s, nonspecific discomfort,

anorexia, pancreatitis, GI bleeding/anaemia

Management

• Surveillance• FAP patients with small lesions (<1cm)

• Surgery– Radical resection– Local excision

• Endoscopic excision• Palliative stenting

Pancreaticoduodenectomy• Historical gold standard (1909)• Definitive• Eliminates need for surveillance (sporadic)• Outcomes– Recurrence rates for adenoma ≈ 0– Adverse events

• Operative mortality 0-9%• Morbidity 25-65% (anastomotic dehiscence and fistulae)• Related to case volume

Local surgical excision

• Entails mobilization of the duodenum and longitudinal duodenotomy - followed by….(i) Simple excision of the ampullary neoplasm(ii)Extended excision (including adjacent duodenal and ductal tissue)

• Lower complications rates(1)–Mortality 0-4%–Morbidity 14-27%

• Recurrence rates up to 30%(2)1.de Castro Surgery 2004 2.Winter J

Gastrointest Surg 2010

Endoscopic ampullectomy

• Described in the late 1980’s• Developed as a less invasive alternative• ASGE guideline 2007– Outcomes• Largely retrospective data

– Success rates for removal 46-92%

Outcomes

Ceppa Annals of Surg 2013

Complications El Hajj Gastrointest Endos Clin N Am 2013

Patient Selection

• Endoscopy– Suspicious features – induration and rigidity of papilla,

ulceration, submucosal mass effect, friability– Biopsy1,2

• High sensitivity (>90%) for detecting the presence of an adenoma• Low sensitivity for confirming adenocarcinoma – missing the

diagnosis in 30%

• The frequency of malignant foci in ampullary adenomas is 26-30%

• Accuracy improved– Number of biopsies > 6– Biopsies taken after ERCP

1.Artifon GIE 2009 2.Sauvanet Am J Surg 1997

Staging

• Staging– EUS +/- IDUS• Depth of involvement – T stage • Intraductal extension• Periampullary LN’s

– CT/MRI -• nodal staging and metastases

– ERCP• Main role is at the time of resection to assess

intraductal extension (PD and CBD)

Proposed algorithm