From endoscopic resection to pancreatoduodenectomy: a narrative review of treatment modalities for the tumors of the ampulla of Vater

Abstract

Background and Objective: Tumors of the ampulla of Vater are a rare set of lesions that arise at the confluence of the common bile duct (CBD) and the pancreatic duct. They can be benign or malignant, often not easy to discriminate before treatment. Malignant tumors have low chances of survival (overall 5-year survival between 0% and 60%) and surgery is still the only curative option. Prognostic factors are being investigated to tailor therapeutic approach and improve outcomes. Due to their location in a complex anatomical region, all treatment options are challenging and associated with relevant morbidity. In this review we discuss different excisional techniques for the treatment of ampullary tumors (AT). Methods: A review of medical databases (PubMed and Google Scholar) was conducted selecting most relevant articles in English language without a specific timeframe. After first selection, most relevant citations were identified through snowballing. Key Content and Findings: Pancreatoduodenectomy (PD) is the gold standard in malignant tumors, achieving the most radical treatment, at the price of worse perioperative morbidity/mortality and quality of life. Trans-duodenal ampullectomy (TDA) was developed before endoscopic resection (ER) and maintains a role only in selected patients. ER is now the first choice for benign lesions and expanding towards early stages malignant AT. Conclusions: Pancreatodudenectomy remains the best option for the radical excision of malignant AT, recently being offered also via minimally invasive approach. However, in early-stage malignant tumors, ER is gaining importance with foreseeable further expansion. Transduodenal ampullectomy still has a role in selected patients, such as unfit for PD when ER is not possible mainly due to anatomical abnormalities.