Surgical therapy of juxtapapillary tumors

Tumors of the papilla of Vater represent a pathophysiological entity. We propose a precise definition of these tumors and give a summary of diagnostics and therapy as well as a review of the literature.

The most accurate definition includes all tumors originating within one cm of the papilla, regardless of their histology. We therefore use the term of "juxtapapillary tumors". Early symptoms are itching, jaundice, sometimes pain and cholangitis/cholecystitis. The first diagnostic means are sonography, CT-scan, ERCP and angiography. The therapeutic options range from pure palliation by stenting or bypass surgery with the specific option of transduodenal local tumor excision to the curative intention of a radical pylorus preserving duodenopancreatectomy (Whipple resection).

Prognostic factors include growth pattern, histology, stage and lymph node involvement of the tumor. Another, new method with prognostic value seems to be the DNA-fingerprinting. A literature review of the different therapeutic modalities shows the following results: After stenting, the median survival is 10 months. The median 5-year survival after local excision and radical resection lies between 30-50%, with huge differences according to tumor stage.

With a strict definition, more precise guide-lines concerning the therapy of such tumors seem adequate. These depend on tumor stage and dignity, general health condition of the patient and experience of the institution. Considering the low perioperative mortality of radical resection (actually below 5%), there will be increasing indications for this option in the future. But nevertheless, there are good palliative alternatives for selected cases.