Pancreatoduodenectomy (PD) is the treatment of choice for ampulla of Vater (AoV) cancer. Although the incidence of lymph node metastasis is approximately 47% , and it is associated with poor prognostic biologic behavior, the curative resection of AoV cancer shows the most favorable long-term oncologic outcome by radical pancreatectomy among periampullary cancers [2,3].
What about premalignant lesions of the AoV? With the advancement in experiences and technologies of endoscopy, endoscopic papillectomy (EP) is a safe treatment modality for premalignant lesions of the AoV area. EP is usually attempted for tumors with no malignancy potential and has been confirmed benign by prior biopsy of tumors (<4.5 cm in diameter). The success rate of EP in the AoV area is 61% to 92%, and the recurrence rate is 0% to 33%. Complications of EP include pancreatitis in approximately 8% to 12% of cases and bleeding in 2% to 7% of cases. Perforation occurs in approximately 2% to 4% of cases, and in rare cases, mortality (0.3%–7%) may also occur . In clinical practice, patients with potentially residual ampullary lesions after EP are common. Transduodenal ampullectomy (TDA) was reserved for such patients.
Generally, TDA is thought to be less aggressive and function-preserving surgery compared with PD; however, it still involves complex surgical processes, such as septoplasty for common channel formation between the bile and pancreatic ducts and common channel duodenal implantation. Therefore, it is typically performed using an open procedure. In theory, patients with potential indications for TDA are expected to have long-term survival, and a minimally invasive approach would be ideal, as long as the appropriate surgical technique and skills are available. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic approaches of TDA with its technical pitfalls and future perspectives for treating premalignant lesions of AoV.
The surgical techniques and principles of TDA are the same, regardless of the surgical approaches. After exposure of the pancreaticoduodenal unit from the retroperitoneum, identification of AoV lesions is necessary because the duodenostomy site should be determined for an appropriate surgical approach to the AoV area. In the open approach (Fig. 1A), a small catheter was introduced into the AoV through the cystic duct, which could be easily identified by palpating the tip of the catheter on the duodenal wall. In contrast, in the laparoscopic (Fig. 1B) and robotic approaches (Fig. 1C), the effectiveness of palpation was limited, and intraoperative ultrasound to detect the previous endoscopic retrograde biliary drainage catheter or preoperatively placed endoscopic clips near the AoV could be applied to define the exact duodenal opening site. After identifying the AoV lesions, several stay sutures (4–0 absorbable) with sufficient healthy mucosal margins were placed for effective traction of the ampullary lesion. In procedure, we did not inject saline into the mucosa, and electrocautery was applied to resect the AoV for identifying the bile and pancreatic ducts to resect the whole layer of lesion. After complete resection of the AoV with the bile and pancreatic ducts, several sutures (6–0 absorbable) were placed for a septoplasty to allow the separate bile and pancreatic ducts into a common channel. And mount the stent by fixing it to the bile and pancreatic ducts. Finally, the duodenal mucosa was approximated to the common channel to complete the duodenal implantation of the common channel. After repairing the duodenostomy site, two silastic drains were placed before the external wound closure. Lymph node dissection was not performed because the risk of morbidity increased due to a larger dissection in TDA. None of the patients showed abnormal postoperative findings (Table 1). In the laparoscopic case, the hospital stay was prolonged due to vomiting, but in other cases, there were no other special complications. The pain index appeared to be better for the robot cases (Table 2); however, it was difficult to compare it as a subjective index for each patient.
Compared with PD, the surgical extent of TDA is limited; hence, it is thought to be an appropriate surgical option for treating premalignant lesions of AoV. Therefore, preoperative endoscopic ultrasonography and intraoperative frozen section test should be routinely performed to confirm the diagnosis and depth of lesion invasion before performing TDA. All four patients performed this study and had reported premalignancy pathology in postoperative pathologic diagnosis, indicating that accurate patient selection is important for TDA.
Fortunately, there are no advanced T stage cases. But even in advanced cases, according to a Korean multicenter study, there was no difference in prognosis between PD and TDA when Tis and T1 stages were reported . With advances in laparoscopic skills and experience, several reports have demonstrated the technical feasibility and safety of TDA [6,7]. However, TDA usually requires an open approach due to complicated surgical procedures; consequently, minimally invasive approaches to TDA are rarely reported.
Several rationales exist for minimally invasive TDA for premalignant lesions of the AoV. First, the surgical extent of TDA is limited compared to the external wound for the open approach. It can benefit from a minimally invasive approach because the dissection-induced injury is smaller than access-induced injury. Second, long-term survival is expected for these patients. Quality of life should be considered to minimize cosmetic complications.
As shown in the present cases, an accurate suturing technique not only for creating a common channel between the small bile and pancreatic ducts but also for its implantation surrounding the folded duodenal mucosa is critical to complete the TDA. The laparoscopic approach is appropriate yet difficult for this surgical procedure. Based on three consecutive experiences of TDA for premalignant lesions of AoV, we believe that the robotic approach makes it much easier to complete these complicated and delicate surgical procedures. The wrist-like function of the surgical instruments and the stable three-dimensional magnified operation field provided by the robotic surgical system are thought to be useful. In the present cases, the operation time of the robot cases is longer than other approaches, which can be explained by the existence of docking time and the learning curve, and there is a sufficient possibility that the operation time will be shorter.
However, applying the robotic surgical system as a routine practice is difficult because of the high cost of robotic surgery. Recently, the Ministry of Food and Drug Safety in Korea approved the clinical use of Revo-i (the Korean robotic surgical system; Meerecompany Inc., Seoul, Korea) in minimally invasive surgery [8,9]. In addition, several international companies are actively involved in robotic surgical system development . A day where patients would take advantage of robotic TDA with much available cost is believed to arrive soon.
In summary, we are living in an era intermingled with different surgical TDA approaches, including open, laparoscopic, and robotic systems. Currently, these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly using the robotic approach, is ideal. Considering the surgical complexity of TDA, robotic TDA is considered to be effective. Further clinical applications of robotic TDA are expected to increase in the near future.
This study was approved by Institutional Review Board of Yonsei University College of Medicine with a waiver of informed consent (No. 4-2022-0102).
Formal analysis: JEJ
Project administration: CMK
Writing–original draft: DJ
Writing–review & editing: All authors
All authors read and approved the final manuscript.
All authors have no conflicts of interest to declare.