PERIAMPULLARY CANCERS

Abstract

By definition, periampullary cancers arise within 2 cm of the major papilla in the duodenum. They encompass four different types of cancers: ampullary (ampulla of Vater), biliary (intrapancreatic distal bile duct), pancreatic (head–uncinate process), and duodenal (mainly from the second portion). Although these tumors have different origins, the complex regional anatomy and their proximation within that confined region generally dictate a common operative approach. Radical resections, such as the Whipple procedure ⁶² or its variant with preservation of the pylorus with or without extended regional lymphadenectomy,⁵⁸ have been the main treatments for these cancers, especially with the currently low morbidity and mortality rates.⁶⁷ Although the perioperative outcomes for these different cancers are similar, the long-term survival has traditionally varied. Consequently, because exact tumor origin is often difficult to clinically ascertain, surgeons have favored an aggressive approach toward resection to benefit those patients harboring cancers with a better prognosis. This observation has intrigued physicians managing patients with these cancers. It is unknown why outcome should vary for adenocarcinomas arising from different anatomic sites in such close proximity. Indeed, if survival does vary significantly for these cancers as clinical impression suggests, clearly, factors other than anatomy alone must be involved.

This article explores whether there are differences in the clinical behavior of the periampullary cancers and defines which of these factors, if any, affect outcome. Moreover, it is important to determine which factors are valuable clinically so that they can be used to improve overall survival rates.