Ampullectomy

Ampullectomy refers to the surgical removal of the ampulla of Vater, which is the opening through which the bile and pancreatic duct secretions enter the duodenum (the initial section of the small intestine).

The procedure is done for the treatment of ampullary cancer (cancer in the ampulla of Vater), neuroendocrine tumours (tumours that originate in the cells that have characteristics of both nerves and hormone-producing cells), and inflammatory stenosis (a noncancerous condition).

Ampullary cancer is a rarely occurring cancer that gives the individual a higher chance of survival than cancers of the pancreas, intestines, and surrounding organs. When cancer blocks the ampulla of Vater, the drainage of the bile and pancreatic duct secretions into the duodenum is blocked, and the secretions accumulate in the blood, causing jaundice (yellowing of the skin).

Ampullectomy will be advised in individuals with ampullary cancer. Symptoms of this cancer include: 

• Jaundice
• Diarrhoea
• Weight loss
• Loss of appetite
• Abdominal pain
• Gastrointestinal bleeding
• Pancreatitis
• Jaundice
• Back pain
• Vomiting and nausea
• Greasy, pale stools

This surgery is also performed in cases of benign (noncancerous) ampullary lesions (a region in the tissue that is damaged due to disease).

A person will be eligible for the surgery if:

• The tumour is ≤2 centimetres (cm) in size
• The cancer has not spread to the lymph nodes on imaging tests
• Cancer is in the early stages

Ampullectomy is contraindicated in the following cases:

• The cancer has spread to the nearby tissue
• Lesions with advanced intraductal involvement (lesions that have spread to the pancreatic and bile ducts)
• Tumour size >4 to 5 cm

You will need to visit the surgeon a few days prior to the surgery for a preoperative assessment, wherein you will be asked to share the following details:

• Medical history
• A list of medications that you take, including supplements and vitamins
• Whether you are pregnant

Your doctor will perform a physical examination and order the following diagnostic and radiological tests:

• Blood and urine tests
• Computed tomography (CT) scan
• Magnetic resonance imaging cholangiopancreatography (an imaging technique to produce images of the bile and pancreatic ducts)
• Chest X-ray
• Electrocardiogram (ECG)
• An endoscopic biopsy (collection of a tissue sample with the help of an endoscope [a tube with a camera and light source at one end]) 

In addition, the surgeon will provide the following instructions to help you prepare for the surgery:

• Discontinue blood thinners like ibuprofen and aspirin a week before the surgery.
• Fast from midnight prior to the surgery.
• If you are a regular smoker, the surgeon will ask you to stop smoking.
• Bowel preparation will be required to empty the bowels before the surgery.
• Tell the surgeon if you have a cold, flu, or fever in the days leading to the surgery. In such a case, your surgery may be postponed.
• You will have to sign an approval form if you agree to the procedure.
• Make sure to arrange for a friend, family member, or responsible adult to drive you home after the surgery.

After you arrive at the hospital, the hospital staff will ask you to undress and wear a hospital gown. You will be asked to lie on your back, and a catheter will be inserted in a vein in your arm to provide you with essential fluids and medicines during the surgery intravenously (IV). Antibiotics will be given through the IV to prevent infection before taking you to the operating room. 

The surgery will be done under general anaesthesia (a medicine given to make you fall asleep). Once you are under the influence of general anaesthesia, a catheter (tube) will be inserted in your bladder to drain urine. Additionally, you will be given compression stockings to prevent the formation of blood clots.

The surgery is then done in the following way:

• Open ampullectomy:
  • The surgeon will make an incision (cut) in the midline on your upper abdomen. 
  • He/she will explore your abdominal cavity and free your duodenum (initial part of the small intestine) and pancreatic head (located on the right side of the abdomen and attached to the duodenum) from the retroperitoneum (space behind the abdominal and peritoneal cavity).
  • The surgeon will take a sample of your lymph nodes near the affected area and send it for examination to check for the spread of cancer. 
  • Next, he/she will identify your bile and pancreatic duct and ampulla of Vater and excise the ampulla without affecting the bile and pancreatic duct. Along with it, the surgeon will also remove a small margin of tissue around the affected area for complete excision.
  • The surgeon will reconstruct the common bile and pancreatic duct using stitches. The reconstruction is completed by reinserting the duct and closing the duodenal wall.
  • If the gall bladder is present during the surgery, the surgeon may remove it too to prevent any complications.
  • Finally, he/she will close the cut with staples or absorbable stitches.
• Minimally invasive surgery: The surgeon will make small incisions on your abdomen and pass a thin tube with a camera and light (laparoscope) along with small instruments through these incisions to perform the surgery. 
• Robot-assisted surgery: It is performed by making small incisions on the abdomen through which a laparoscope and instruments are passed and controlled with the help of a computer console placed outside.
• Endoscopic ampullectomy: Here, the ampullectomy for benign, small lesions will be performed with the help of a duodenoscope (passed in through the mouth). The lesion is examined by moving it slightly and then cut off with the help of the duodenoscope.

The surgery takes about three hours. After your operation, the hospital staff will take you to the recovery room where your vital signs (temperature, blood pressure) will be taken regularly. You may get oxygen through a mask and painkillers will be given to you.

You will not be able to eat or drink for about four hours following the procedure, but clear liquids will be given thereafter till the next day. 

Proton pump inhibitors will be administered to you through IV to reduce the acid secretion in your stomach.

The medical staff will encourage you to move around and eat and drink to speed up your recovery. You will be asked to perform exercises such as rotating your feet or bending your knees to prevent blood clots in your legs.

The urinary catheter will be removed on the day after the surgery.

After reaching home, you will need to take the following care:

• Wound care: Do not apply any ointment or lotion on the incision. Avoid wearing tight clothes or fabrics that may cause irritation in the operated area. 
• Shower: You may be allowed to shower after two days of the procedure, but do not swim or enter a bathtub or hot tub. Avoid using a wipe cloth to rub on the wound. Instead, gently pat it dry. 
• Pain medicine: Take pain medicines only as prescribed. Gradually reduce their consumption as the pain subsides. 
• Driving: You will be allowed to drive after you have stopped taking pain medicines, i.e., after one to two weeks.
• Activity: Do not carry any heavy objects for at least six weeks. You can climb stairs and walk as much as tolerated. 
• Diet: You may have your usual diet.
• Work: You can resume work in about four to six weeks after the surgery.

The benefits of the surgery include:

• Removes tumour without damaging nearby tissues
• Requires a short hospital stay
• Less complications as it is less extensive
• Relieves symptoms

When to see the doctor?

Consult your healthcare practitioner immediately if you notice any of the following symptoms:

• Opening of the incision
• Fever
• Pain while urination
• Rashes
• Severe abdominal pain
• Difficulty in breathing
• Chest pain
• Blood or fluid discharge from the incision
• Nausea and vomiting

Some possible complications of ampullectomy include:

• Bleeding
• Pancreatitis
• Perforation in bowels
• Damage to the bowels, ureter, or bladder
• Infection
• Hernia (muscle weakness causing lump formation)
• Bowel obstruction

Your follow-up will be scheduled in about a week or two after the procedure to review your progress.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.