Laparoscopic Versus Open Pancreatoduodenectomy for Periampullary Tumors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: Laparoscopic pancreatoduodenectomy (LPD) has emerged as an alternative to open technique in treating periampullary tumors. However, the safety and efficacy of LPD compared to open pancreatoduodenectomy (OPD) remain unclear. Thus, we conducted an updated meta-analysis to evaluate the efficacy and safety of LPD versus OPD in patients with periampullary tumors, with a particular focus on the pancreatic ductal adenocarcinoma patient subgroup. METHODS: According to PRISMA guidelines, we searched PubMed, Embase, and Cochrane Library in December 2023 for randomized controlled trials (RCTs) that directly compare LPD versus OPD in patients with periampullary tumors. Endpoints and sensitive analysis were conducted for short-term endpoints. All statistical analysis was performed using R software version 4.3.1 with a random-effects model. RESULTS: Five RCTs yielding 1018 patients with periampullary tumors were included, of whom 511 (50.2%) were randomized to the LPD group. Total follow-up time was 90 days. LPD was associated with a longer operation time (MD 66.75; 95% CI 26.59 to 106.92; p = 0.001; I2 = 87%; Fig. 1A), lower intraoperative blood loss (MD - 124.05; 95% CI - 178.56 to - 69.53; p < 0.001; I2 = 86%; Fig. 1B), and shorter length of stay (MD - 1.37; 95% IC - 2.31 to - 0.43; p = 0.004; I2 = 14%; Fig. 1C) as compared with OPD. In terms of 90-day mortality rates and number of lymph nodes yield, no significant differences were found between both groups. CONCLUSION: Our meta-analysis of RCTs suggests that LPD is an effective and safe alternative for patients with periampullary tumors, with lower intraoperative blood loss and shorter length of stay.

Comparison of the two histological subtypes of ampullary adenocarcinoma: a retrospective study.

OBJECTIVES: This study aimed to compare the intestinal and pancreatobiliary subtypes of ampullary adenocarcinoma in a large patient group due to limited data on survival and risk factors. METHODS: A retrospective analysis of the clinical and pathological findings and the survival of 184 patients with ampullary adenocarcinoma who underwent curative operation between 2007 and 2018 was performed. RESULTS: Pancreatobiliary subtype had a higher prevalence of jaundice before operation than the intestinal subtype (p < 0.05). Pancreatobiliary subtype had a larger tumor size (> 2 mm) (p < 0.01) and poorer differentiation (p < 0.05) than the intestinal subtype. Perineural invasion more frequently occurred in pancreatobiliary subtype than the intestinal subtype (p < 0.01) and pancreatobiliary subtype had a higher prevalence of positive dissected lymph nodes (p < 0.05) with an advanced disease stage (p < 0.01) than the intestinal subtype. Patients of the pancreatobiliary subtype had poorer disease-free and overall survival than patients of the intestinal subtype. No survival benefit of adjuvant chemotherapy was found in either patients of the intestinal subtype or pancreatobiliary subtype. No significant difference was found in any subtypes regarding the recurrent regions. CONCLUSIONS: Pancreatobiliary subtype exhibited a higher recurrence rate and a poorer overall survival rate with more unfavorable pathological characteristics than the intestinal subtype.

OBJETIVOS: Los datos sobre la supervivencia y los factores de riesgo del adenocarcinoma ampular son limitados debido a su rareza. Este estudio buscó comparar el subtipo intestinal y el subtipo pancreático-biliar en pacientes con adenocarcinoma ampular. MÉTODOS: Análisis retrospectivo de hallazgos clínicos y patológicos y la supervivencia de 184 pacientes con adenocarcinoma ampular tratados entre 2007 y 2018. RESULTADOS: El subtipo pancreático-biliar tuvo una mayor prevalencia de ictericia antes de la operación y un tamaño de tumor mayor, y una peor diferenciación, que el subtipo intestinal. La invasión perineural fue más frecuente en el subtipo pancreático-biliar, con una mayor prevalencia de linfonodos disecados positivos y un estadio avanzado de la enfermedad. Los pacientes del subtipo pancreático-biliar tuvieron una supervivencia libre de enfermedad y una supervivencia general peores que los pacientes del subtipo intestinal. No se encontró ningún beneficio de la quimioterapia adyuvante en pacientes del subtipo intestinal o pancreático-biliar. No hubo diferencia significativa en las regiones recurrentes. CONCLUSIÓN: El subtipo pancreático-biliar mostró una tasa de recurrencia y una tasa de supervivencia general peores, con características patológicas más desfavorables que el subtipo intestinal.

Prognostic value of nodal staging classification and number of examined lymph nodes among patients with ampullary cancer.

BACKGROUND: Metastatic disease in the regional lymph nodes (LNs) is a strong indicator of worse outcomes among patients after curative-intent resection of ampullary cancer (AC). This study aimed to ascertain the threshold number of examined LNs (ELNs) for AC to compare the prognosis accuracy of various nodal classification schemes relative to long-term prognosis. METHODS: Patients who underwent pancreatoduodenectomy (PD) for AC (2004-2019) were identified using the National Cancer Database. Locally weighted regression scatter plot smoothing (LOWESS) curves were used to ascertain the optimal cut point for ELNs. The accuracy of the American Joint Committee on Cancer N classification, LN ratio, and log odds transformation (LODDS) ratio to stratify patients relative to survival was examined. RESULTS: Among 8127 patients with AC, 67% were male with a median age of 67 years (IQR, 59-74). Tumors were most frequently classified as T3 (34.9%), followed by T2 (30.6%); T1 (12.9%) and T4 (17.6%) were less common. LN metastasis was identified in 4606 patients (56.7%). Among patients with nodal disease, 37.0% and 19.7% had N1 and N2 disease, respectively. The LOWESS curves identified an inflection cutoff point in the hazard of survival at 20 ELNs. The survival benefit of 20 ELNs was more pronounced among patients without LN metastasis vs patients with N1 disease (median overall survival [OS]: 54.1 months [IQR, 45.9-62.1] in ≥20 ELNs vs 39.0 months [IQR, 35.8-42.2] in <20 ELNs; P < .001) or N2 disease (median OS: 22.5 months [IQR, 18.9-26.2] in ≥20 ELNs vs 25.4 months [IQR, 23.3-27.6] in <20 ELNs; P < .001). When comparing the 4 different N classification schemes, the LODDS classification scheme yielded the highest predictive ability. CONCLUSIONS: Evaluation of a minimum of 20 LNs was needed to stratify patients with AC relative to the prognosis and to minimize stage migration. The LODDS nodal classification scheme had the highest prognostic accuracy to differentiate survival among patients after PD for AC.

Prognostic Factors of Long-term Survival Following Radical Resection for Ampullary Carcinoma.

BACKGROUND: The incidence of adenocarcinoma of the ampulla of Vater has been increasing over the past years. Nevertheless, it is still a rare disease and the prognostic factors predicting long-term survival are not sufficiently clarified. This study aims to evaluate the association between histopathological characteristics and long-term survival of patients with ampullary cancer after curative resection, as well as the efficiency of immunohistochemical expression of CK7, CK20, and CDX2 to distinguish the histopathological (intestinal or pancreaticobiliary) patterns. METHODS: Demographic, histopathological data, pTNM stage, and immunohistochemical expression patterns were collected from 65 patients with adenocarcinoma of the ampulla of Vater. Five and 10-year overall and disease-free survival rates after curative resection were determined. RESULTS: Of the 65 patients with ampullary carcinoma, 47 (72%) underwent radical resection. The 5- and 10-year overall survival rate was 46% and 37%, respectively. Our results demonstrate that the main prognostic factors were the presence and number of lymph node metastases, lymph node ratio (LNR), differentiation grade, and lymphovascular invasion. After multivariate analysis, only lymph node ratio ≥ 20% remained an independent prognostic factor of survival (HR: 2.63 95% CI: 1.05-6.61; p = 0.039). CONCLUSION: Here, we demonstrated more evidence that the lymph node metastases are associated with poor prognosis in ampullary carcinoma. Particularly, the relation between the number of metastatic lymph nodes and the number of harvested lymph node (LNR) should be considered a major prognostic factor.

Adjuvant therapy for true ampullary cancer: a systematic review.

BACKGROUND: Given the lack of evidence on the best adjuvant approach, this review closely examines optimal adjuvant management for resected true ampullary cancer and its histological subtypes. MATERIALS AND METHODS: A comprehensive literature search of PubMed was performed to identify studies on resected true ampullary cancers, published between January 2010 and December 2018. Data including the use of radiation, chemotherapy or chemoradiation and the outcomes were extracted. RESULTS: A total of 116 records were identified, of which 65 screened were selected. Finally, nine studies were included. Only two of the studies reported separately the outcomes of pancreatobiliary and intestinal subtypes. Patients in the selected studies were treated with a pancreaticoduodenectomy with negative margins. Patients treated with adjuvant therapy were more likely to be pT3-4 and have positive nodes; median survival ranged from 30 to 47 months. A significant benefit for adjuvant treatment was observed in four of the studies, restricted to patients at stage IIB or higher. Likewise, patients with positive nodes may have a longer median survival with adjuvant chemoradiation compared to observation. CONCLUSIONS: The present review suggests a benefit for adjuvant treatment for patients with locally advanced tumors. Randomized trials are needed to ascertain the topic, as well as studies reporting toxicity and quality of life of resected true ampullary cancer patients.

Carcinosarcoma of the ampulla of Vater.

Carcinosarcomas, are very rare tumors in gastrointestinal tract, and at the ampulla of Vater location, are extremely uncommon. They are also called spindle cell carcinomas or sarcomatoid carcinomas. These tumors have an aggressive clinical course with frequent metastasis. We report the case of a male patient of 64 y.o with anemia and jaundice, and a diagnosis of carcinosarcoma of the ampulla of Vater.

MicroRNA modulated networks of adaptive and innate immune response in pancreatic ductal adenocarcinoma.

Despite progress in treatment strategies, only ~24% of pancreatic ductal adenocarcinoma (PDAC) patients survive >1 year. Our goal was to elucidate deregulated pathways modulated by microRNAs (miRNAs) in PDAC and Vater ampulla (AMP) cancers. Global miRNA expression was identified in 19 PDAC, 6 AMP and 25 paired, histologically normal pancreatic tissues using the GeneChip 4.0 miRNA arrays. Computational approaches were used for miRNA target prediction/identification of miRNA-regulated pathways. Target gene expression was validated in 178 pancreatic cancer and 4 pancreatic normal tissues from The Cancer Genome Atlas (TCGA). 20 miRNAs were significantly deregulated (FC≥2 and p<0.05) (15 down- and 5 up-regulated) in PDAC. miR-216 family (miR-216a-3p, miR-216a-5p, miR-216b-3p and miR-216b-5p) was consistently down-regulated in PDAC. miRNA-modulated pathways are associated with innate and adaptive immune system responses in PDAC. AMP cancers showed 8 down- and 1 up-regulated miRNAs (FDR p<0.05). Most enriched pathways (p<0.01) were RAS and Nerve Growth Factor signaling. PDAC and AMP display different global miRNA expression profiles and miRNA regulated networks/tumorigenesis pathways. The immune response was enriched in PDAC, suggesting the existence of immune checkpoint pathways more relevant to PDAC than AMP.

Clinicopathological features related to survival in adenocarcinoma of the Vaterian system in a Mexican population.

Adenocarcinomas of the ampulla of Vater account for 0.5% of malignant neoplasms of the gastrointestinal tract and 6% to 20% of malignant periampullary neoplasms, with most patients being candidates for elective surgery. Our objective was to evaluate the clinicopathological prognostic factors of ampullary adenocarcinomas after surgical resection in a Mexican population. From the records of the Department of Pathology at the Instituto Nacional de Cancerología, México, cases diagnosed as adenocarcinomas of the ampulla of Vater were selected over a period of 11 years, from January 2005 to September 2015. Cases with a pancreaticoduodenectomy report were included, and from each case, demographic and pathological data of the surgical specimen were obtained. Univariate and multivariate statistical analyses were performed using the log-rank test and Cox regression. Of 157 cases diagnosed as ampullary adenocarcinomas, 104 patients were excluded as not eligible for surgical treatment at the time of diagnosis. In the remaining 53 patients, a pancreaticoduodenectomy was performed. The mean age of the entire group was 55.4 years, and most were men. Intestinal-type adenocarcinomas were more frequent (77.4%) than pancreatobiliary-type (15.1%), with most being without perineural invasion, well to moderately differentiated, and less than 3 cm in size. Lymph node metastasis and age greater than 65 years had a negative impact on overall survival of the patients. The most convenient classification of malignant epithelial tumors of the Vaterian system is according to the histopathologic phenotype grouped into intestinal-, pancreatobiliary-, and mixed-type adenocarcinomas, as well as uncommon variants.

Immunohistochemical Predictors for Intestinal and Pancreatobiliary Types of Adenocarcinoma of The Ampulla of Vater.

OBJECTIVES: To investigate immunohistochemical predictors for intestinal and pancreatobiliary types of adenocarcinoma of ampulla of Vater and identify clinicopathological characteristics associated with the histological types and patient survival. METHODS: Immunohistochemical markers included MUC1, MUC2, MUC5AC, CDX2, CK7, and CK20. The data were analyzed by univariate and multivariate methods. The two-step cluster method was used to determine the best immunohistochemical markers to discriminate the intestinal from the pancreatobiliary type. RESULTS: This study identified 9 (33.3%) intestinal and 21 (66.7%) pancreatobiliary tumors. CK7 and CDX2 achieved the highest value (= 1) as predictor markers, while CK20, MUC1, and MUC2 showed degrees of importance equal to 0.77, 0.71, and 0.68, respectively. MUC5AC did not reach 0.50 of importance. In the univariate analysis, lymph node involvement, staging (TNM), and angiolymphatic and perineural invasions were associated with histological types. The independent clinicopathological variable in the multivariate model to predict the histological type was angiolymphatic invasion (p = 0.005), OR = 17 (95% CI 2.33 to 123.83). The final model showed positive nodes (N1) associated with shorter survival (HR = 9.5; p = 0.006). Overall survival at 12, 36, and 60 months was 88.5, 67.0, and 47.6%, respectively. CONCLUSIONS: CDX2 and CK7 were the immunohistochemical markers that best discriminated the intestinal from the pancreatobiliary type. Lymph node involvement had a high impact on survival and proved to be more frequent in the pancreatobiliary type.

Intraobserver and Interobserver Variability in the Assessment of Dysplasia in Ampullary Mucosal Biopsies.

Endoscopic mucosal biopsies of the ampulla of Vater (AmpBx) are obtained to histologically assess for dysplasia or carcinoma. However, biopsy material is often scant and a host of factors can induce histologic changes that pose diagnostic challenges. We sought to investigate observer variability in interpretation of AmpBx and the impact clinical data may have on diagnostic interpretation. Thirty-one cases from institutional archives were selected, including 12 cases of reactive atypia (RA), 8 indefinite for dysplasia (ID), and 11 showing low-grade dysplasia (LGD). Slides were independently reviewed at 3 time points with and without clinical information by 6 pathologists who categorized the biopsies RA, ID, or LGD. Following the reviews, intraobserver and interobserver agreement was assessed. Review of AmpBx without clinical data showed fair (κ, 0.27), poor (κ, 0.07), and good (κ, 0.42) interobserver agreement for diagnoses of RA, ID, and LGD, respectively. Interobserver agreement improved for LGD (κ, 0.66 and 0.73) when clinical information was provided; however, agreement remained fair for RA (κ, 0.4 and 0.42) and poor-to-fair for ID (κ, 0.17 and 0.25). When follow-up data were reviewed, all cases that reached unanimous agreement had that diagnosis substantiated by subsequent endoscopic or histologic findings. The same was true of 13 of 19 cases that reached majority consensus. Given the potential clinical consequences of these diagnoses combined with the significant intraobserver and interobserver variability found in this study, we conclude that better-defined diagnostic criteria and consensus reads on difficult cases would assist in the histologic assessment of these challenging cases.

Unusual involvement in mycosis fungoides: Duodenal papilla.

BACKGROUND: Mycosis fungoides (MF) is a type of T-cell lymphoma with cutaneous involvement. It is a rare disease, of low incidence and usually affects middle-aged men. In most cases only the skin is involved although in advanced stages may present with extra cutaneous involvement including the gastrointestinal tract. CASE REPORT: We report the first case of MF with compromise of duodenal papilla, emphasizing the diagnostic approach and a brief review of the subject. DISCUSSION: This case report proves the value of the endoscopic studies in patients with lymphoproliferative disorders, because of the impact in the diagnosis and prognosis. Also, this case report is relevant because there is no scientific evidence, as far as we know, of similar cases reported.

Gastrointestinal stromal tumor of the ampulla of Vater with osteoclastic giant cells, osteoid-like matrix deposition, and aneurysmal bone cyst-like features.

Gastrointestinal stromal tumors are a heterogeneous group with a wide spectrum of histologic features. We describe the first case of 61-year-old woman who presented gastrointestinal stromal tumors of the ampulla of Vater with osteoclast-like giant cells surrounding osteoid-like material and aneurismal bone cyst-like areas. The phenotype was supported by light microscopy and corroborated by immunohistochemistry analysis. Because of the presence of osteoid-like and aneurismal bone cyst-like components, it is first necessary to make differential diagnosis with other entities such as metastatic osteosarcoma. Our case shows another form of differentiation that has not previously been reported.

Prognostic significance of tumour location after adjuvant chemoradiotherapy for periampullary adenocarcinoma.

PURPOSE: To analyse the outcome of adjuvant chemoradiotherapy for periampullary adenocarcinoma and the impact of tumour location as a prognosticator. METHODS AND MATERIALS: Between January 1991 and December 2002, 147 patients with periampullary cancer underwent adjuvant chemoradiotherapy after pancreaticoduodenectomy. Postoperative radiotherapy was delivered to tumour bed and regional lymph nodes up to 40 Gy at 2 Gy/fraction with a two-week planned rest. Intravenous 5-fluorouracil (500 mg/m(2)/day) was given on days 1-3 of each split course. The median follow-up period was 82 months in survivors. RESULTS: Tumour >2 cm and margin-positivity were more common in patients with pancreatic cancer than nonpancreatic periampullary cancers (p<0.0001 and 0.0780, respectively). According to the tumour location, 5-year overall survival rates of ampulla of Vater, distal common bile duct, duodenal and pancreatic head cancers were 53.0%, 50.3%, 37.5%, and 13.0%, respectively (p<0.0001). On multivariate analysis, pancreatic location (p<0.0001) and nodal involvement (p=0.0123) were associated with inferior overall survival. CONCLUSION: Regardless of its advanced histologic features, pancreatic location itself was an adverse prognostic factor affecting overall survival.

Resección endoscópica de adenoma gigante de la ampolla de Vater con crecimiento intraductal: a propósito de un caso / Endoscopic resection of a giant adenoma of the ampulla of vater with intraductal growth: report of a case

Los tumores ampulares representan un grupo diverso aunque infrecuente de lesiones ubicadas en la confluencia de los conductos pancreático y biliar. Representan el 1-2% de los tumores del tracto digestivo, estos pueden ser benignos y malignos. Entre los tumores benignos, el adenoma es el más frecuente y su incidencia oscila entre 0,04 y 0,12%. Pueden ser sésiles o pediculados e histológicamente diferenciarse en tubulares, túbulo-vellosos y vellosos. Debido a su potencial maligno, el tratamiento recomendado es la resección bien sea quirúrgica o endoscópica; esta última indicada en tumores menores de 4,5cm. Se reporta el caso de paciente masculino de 78 años quien consultó por ictericia, dolor abdominal y pérdida de peso de 2 meses de evolución. Se realizó ultrasonido y tomografía abdominal que reportan imagen sólida en confluente biliopancreático. Se realizó duodenoscopia encontrando tumoración ampular de 6 centímetros de diámetro de aspecto velloso. Dada la edad y comorbilidades del paciente se decidió ampulectomía endoscópica parcelar. En la colangiografía retrograda endoscópica se observó imagen de defecto en tercio distal de colédoco por lo que se procedió a extraer con balón de Fogarty, obteniéndose masa tumoral de aspecto velloso pediculada la cual es resecada sin complicaciones. El hallazgo histopatológico reportó adenoma túbulo-velloso con displasia de bajo grado y en controles endoscópicos e histológicos de seguimiento a los 10 meses del procedimiento no se ha evidenciado recidiva tumoral y clínicamente el paciente se encuentra asintomático y en buenas condiciones generales

Ampullary tumors represent a various group but uncommon lesions located at the confluence of the pancreatic and bile ducts. They account for 1 to 2% of the digestive tract tumors, they may be benign and malignant. Among benign tumors, the adenoma is the most common and its incidence ranges from 0.04 a 0.12%. They can be sessile or pedunculated and histologically differentiated tubular, tubulo villous and villous. Because of its malignant potential, the recommended treatment is surgical resection or endoscopic either, the latter indicated in tumors less 4.5 cm. A case of 78 years old male patient who consulted with jaundice, abdominal pain and two months weight loss. It performed abdominal ultrasound and CT reporting in confluent biliopancreatic solid image. Duodenoscopy was performed finding ampullary tumor six inches diameter appearance fluffy. Considering patient age and comorbidities, it decided parcel endoscopic ampullectomy. In endoscopic retrograde cholangiography, defect image was observed in distal choledochal, so we proceeded to extract with Fogarty Balloon, giving pedunculated villous tumor, which is removed without complications. The histopathological finding was tubule villous adenoma, with low grade dysplasia. In endoscopic and histologycal controls up to procedure ten months, is not clinically evidence tumor recurrence and the patient is asymptomatic in good general conditions

Resultados actuales de la pancreatoduodenectomía para el tratamiento de los tumores periampulares y análisis de factores pronósticos de sobrevida / Results of pancreaticoduodenectomy in the treatment of periampullary tumors

Background: The diagnosis and treatment of periampullary tumors represents a challenge for current medicine. Aim: To review the results of pancreaticoduodenectomy (PDD) in the treatment of periampullary tumors and to identify risk factors that impact the long-term survival. Patients and Methods: We performed a retrospective study of patients who underwent a PDD for periampullary tumors between 1993 and 2009. We reviewed perioperative results and long term survival. We performed a multivariate analysis for long-term survival. Results: A PDD was performed in 181 patients aged 58 ± 12 years (98 females). Piloric preservation was done in 53 percent and a pancreatogastric anastomosis was used in 94 percent of cases. Morbidity was 62 percent and postoperative mortality was 5.5 percent. Pancreatic cancer was the most frequent pathological finding in 41 percent, followed by ampullary cancer in 28 percent and distal bile duct cancer in 16 percent. Median survival was 17 months, with a five years survival of 24 percent. Survival for ampullary tumors was 28 months with a five years survival of 32 percent. The median and five years survival were 14 months and 16 percent for bile duct cancer and 11 months and 14 percent for pancreatic cancer. Multivariate analysis identified tumor type (pancreas /bile duct) and lymph node dissemination as independent predictors of mortality. Conclusions: One quarter of patients experienced long term survival. Mortality predictors were tumor type and lymph node dissemination.

Duodeno-biliary obstruction in Peutz-Jeghers syndrome.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a pathology with autosomal dominant inheritance characterized by the presence of hamartomatous polyposis and mucocutaneous pigmentation. We present a case report from the Hospital General of Mexico. CLINICAL CASE: We present the case of a 28-year-old male. During physical examination we noted hyperpigmented dermatosis of the oral mucosa and lips. The same condition was seen in both palms. The condition evolved with intolerance to oral feeding and progressive obstructive jaundice. Panendoscopy reported pangastric sessile polyps, as well as being pylorus passable. In the second duodenal portion occupying the region of the ampoule of Vater was a sessile polyp that deformed the region. Exit of bile was not observed through the ampoule. Ultrasound and computed tomography of the abdomen corroborated dilatation of the extrahepatic biliary tract. Two endoprostheses were placed in the bile duct by endoscopic cholangiography, with improvement of biliary obstruction. Roux-en-Y astrojejunoanastomosis was performed because of obstruction of the duodenum by polyps between the second and third portion. Jejunal enterotomy was necessary because of the presence of intraluminal injury formed by a conglomerate of polyps. The patient had a satisfactory evolution. Pathological study reported hamartomatous polyps. CONCLUSIONS: Duodenal obstruction secondary to biliary tract obstruction is a rare manifestation associated with PJS. In these cases, the treatment of choice is polyp resection using endoscopic and/or surgical approach as well as management of the biliary tract obstruction.

Ampuloma: ¿terapia endoscópica o quirúrgica? / Ampullary neoplasms: endoscopic or surgical treatment?

Ampullary neoplasms may correspond to adenoma or adenocarcinoma. The study of its staging is performed by means of computed tomography, magnetic resonance imaging and endosonography. The appropriate classification of the stages allows for a better planning of treatment. In benign tumors and small selected carcinoma, ampullectomy (endoscopic or surgical) is an alternative. In patients with ampullary neoplasms invading deep extension or showing high risk of recurrence, without evidence of metastasis, pancreatodudodenectomy is the treatment of choice. In those cases with distant metastasis, palliative treatment is indicated.

Las neoplasias ampulares pueden corresponder a adenomas o adenocarcinomas. El estudio de etapificación se realiza con tomografía computada, resonancia magnética y endosonografía. La correcta clasificación en estadíos, permite planificar de mejor forma el tratamiento. En tumores benignos y seleccionados carcinomas pequeños, la ampulectomía (endoscópica o quirúrgica) es una alternativa. En pacientes con neoplasias ampulares que presentan extensión en profundidad o alto riesgo de recurrencia, sin evidencia de metástasis a distancia, estaría indicada la pancreatoduodenectomía. En aquellos casos con metástasis a distancia, se aplican técnicas paliativas.