Tumor of Vater's ampulla – What is the right management?

Introduction: The adenoma-carcinoma sequence is well-known at tumors of Vater papilla, too. These could be removed endoscopically or surgically with ampullectomy or partial pancreatoduodenectomy.

Case report: A 53 years old male patient was admitted to the hospital with painless jaundice. The abdominal ultrasound examination revealed dilatation of the extra- and intrahepatic bile ducts. ERCP showed a 7mm in diameter filling defect in the suprapapillary area. After papillotomy a villous polyp protruded into the lumen at the lower surface of orifice. It was endoscopically removed and sent for histological evaluation. Afterwards the jaundice disappeared. The histological examination proved a well-differentiated adenocarcinoma, which originated from an adenoma and infiltrated its basis. For the determination of the tumor extension, duodenoscopy and further sampling was done from the surroundings of the polypectomized region, all but one revealed malignancy. The abdominal CT did not show any abnormality. On the basis of these findings, surgical therapy was decided and pylorus- preserving pancreatoduodenectomy was carried out with regional lymphadenectomy. Macroscopically a tumorous alteration could be seen suprapapillary. Microscopically a neoplastic proliferation was detected, originating from the mucosa of the common bile duct and with infiltration of the bile duct and the duodenal wall and perineurally of the serosal fatty tissue. There was lymph node involvement only in one node. The postoperative period was uneventful, except a transient wound healing disorder. Afterwards chemotherapy was started at the patient.

Conclusion: The management of Vater papilla and bile duct tumors could be achieved by multidisciplinary approach, involving the gastroenterologist, radiologist, pathologist and the surgeon. The precise diagnosis and the determination of the tumor extension are needed to choose the optimal treatment.