الفهرس 
Embryology & Anatomy of Periampullary areaOnly 14 pages are availabe for public view
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Abstract
The ampulla of Vater, also known as the
hepatopancreatic ampulla, is formed by the union of the
pancreatic duct and the common bile duct. The ampulla is
specifically located at the major duodenal papilla. The ampulla
of Vater is an important landmark, halfway along the second
part of the duodenum, that marks the anatomical transition
from foregut to midgut (and hence the point where the celiac
trunk stops supplying the gut and the superior mesenteric
artery takes over (Gan,2007).
Carcinoma of the ampulla of Vater is a rare malignant
tumor arising within 2 cm of the distal end of the common bile
duct, where it passes through the wall of the duodenum and
ampullary papilla (Carter, 2008).
Neoplastic transformation of the intestinal mucosa
occurs more commonly near the ampulla than at any other site
in the small intestine. Despite this, primary ampullary tumors
are rare, with an incidence of approximately four to six cases
per million population. They account for only 6 percent of
lesions that arise in the periampullary region but are
responsible for 20 percent of all tumor-related obstructions of
the CBD (Benhamiche, 2003).
Introduction
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Ampullary tumors generally present at an earlier stage
than periampullary tumors. Their strategic location may cause
early biliary obstruction with jaundice (75%), biliary colic,
bleeding or pancreatitis. Serum bilirubin and transaminase
typically are elevated. Jaundice may intermittently wax and
wane because of central necrosis and sloughing or pressure
opening of a minimally obstructed duct (Talamini, 2003).
Diagnostic imaging modalities for patients with
suspected periampullary neoplasms include ultrasonography,
computed tomography scanning, magnetic resonance imaging
(MRI) and magnetic resonance cholangiopancreatography,
endoscopic retrograde cholangiopancreatography,
percutaneous transhepatic cholangiography and positron
emission tomography. With appropriate use of these studies,
one should be able to arrive at the diagnosis of pancreatic
cancer in more than 90% of patients presenting with the
disease (Warshaw, 2003).
Halsted in 1898, was the first who attempted
successfully local resection of a periampullary carcinoma, but
this patient died 7 months later for a recurrent
tumor. Codivilla, was the first to perform en block removal of
the entire duodenum with the head of the pancreas for
periampullary cancer, and Kausch, performed the first
successful such resection using a two-stage approach. A oneIntroduction
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stage pancreaticoduodenectomy was described independently
by Whipple and colleagues (1935) and Brunschwig (1937)
(Holzheimer, 2001).
Pancreaticoduodenectomy has the benefit of a low
recurrence rate, but carries high morbidity (57%) and mortality
rates (7%). Conversely, the lower morbidity (19%) and
mortality (2%) rates of localized resection of the tumor are
associated with higher recurrence rates (23%) (Mean length of
hospital stay ranges from 11 to 13 days following localized
resection and 15-23 days following pancreaticoduodenectomy
(Cahen, 2002).
Since its first description in 1983 by Suzuki et al and the first
large case series in 1993 by Binmoeller et al, endoscopic
ampullectomy has gained widespread acceptance for the
treatment of benign adenomas. Eradication can be achieved in
85% of cases with low morbidity and mortality. Furthermore,
hospitalization can be avoided in most patients, since
endoscopic ampullectomy can usually be performed with
conscious or deep sedation on an outpatient basis (Inmoeller,
2004).