[The endoscopic treatment of carcinoma of Vater's ampulla]

The ampullary carcinoma is a rare tumor. Its early and accurate diagnosis will lead to early treatment and subsequent better prognosis. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be one of the best diagnostic tools. Furthermore an endoscopic biliary drainage procedure: endoscopic sphincterotomy or endoprosthesis placement, can be performed immediately following the diagnostic procedure.

Endoscopic drainage was attempted in 20 patients with a success rate of 90 percent. There were 8 females and 12 males, with a mean age of 71 years (range 43-92), and were admitted to the hospital with obstructive jaundice. Endoscopic insertion of a biliary endoprosthesis (9 cms long 3.2 mm [10 Fr] diameter), was successful in 18 patients whom made uneventful recovery and their jaundice resolved completely.

In 18 of them an endoscopic sphincterotomy was carried out. Two patients developed cholangitis, the endoprosthesis were removed and a new one inserted. The survival rate of these patients was 3 and 18 months respectively. Failure of endoscopic sphincterotomy or endoprosthesis insertion in 2 remaining patients, was ascribed to an inability to cannulate the papilla due to infiltrating tumor. The median survival time in 15 remaining patients was 4 months (1-18 months) and died by metastatic disease. Five patients underwent Whipple's procedure, and all survived the operation. Two died, by metastatic disease, with a median survival time of 16 months and 3 still alive at 46, 25 and 18 months post-operatively. Carcinoma of the ampulla of Vater is not resectable in 25-50% of the patients because of metastatic disease, deep extension of the tumor or general contraindications for major surgery.

Endoscopic sphincterotomy or endoprosthesis insertion as a definitive treatment modality should be reserved for poor surgical candidates and those patients with limited life expectancy due to metastatic disease.