Background and Objective: Tumors of the ampulla of Vater are a rare set of lesions that arise at the confluence of the common bile duct (CBD) and the pancreatic duct. They can be benign or malignant, often not easy to discriminate before treatment. Malignant tumors have low chances of survival (overall 5-year survival between 0% and 60%) and surgery is still the only curative option. Prognostic factors are being investigated to tailor therapeutic approach and improve outcomes. Due to their location in a complex anatomical region, all treatment options are challenging and associated with relevant morbidity. In this review we discuss different excisional techniques for the treatment of ampullary tumors (AT).Methods: A review of medical databases (PubMed and Google Scholar) was conducted selecting most relevant articles in English language without a specific timeframe. After first selection, most relevant citations were identified through snowballing.Key Content and Findings: Pancreatoduodenectomy (PD) is the gold standard in malignant tumors, achieving the most radical treatment, at the price of worse perioperative morbidity/mortality and quality of life. Trans-duodenal ampullectomy (TDA) was developed before endoscopic resection (ER) and maintains a role only in selected patients. ER is now the first choice for benign lesions and expanding towards early stages malignant AT.Conclusions: Pancreatodudenectomy remains the best option for the radical excision of malignant AT, recently being offered also via minimally invasive approach. However, in early-stage malignant tumors, ER is gaining importance with foreseeable further expansion. Transduodenal ampullectomy still has a role in selected patients, such as unfit for PD when ER is not possible mainly due to anatomical abnormalities.
S urgery in the era of coronavirus disease 2019 (COVID-19) is uncharted territory. Non-urgent surgery was discouraged at the beginning of the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The need to reserve intensive care units for patients with COVID-19, the fear of spreading the infection through the hospital, and the possible worsening of surgical outcomes [1] were the main factors that motivated the postponement elective surgery. It has been estimated that as many as 28,404,603 operations were canceled during the first 12-week peak of the pandemic [2]. In the absence of scientific evidence on how best to resume surgical activity, we propose the algorithm used to screen potential surgical patients in a usually high-volume, tertiary referral university hospital in Rome, Italy (Fig. 1). Patients are screened by telephone interview for symptoms and recent contacts. If negative, patients access the hospital the morning of the day before surgery. Both rapid enzyme-linked immunosorbent assay (ELISA) for SARS-CoV-2 immunoglobulin G-immunoglobulin M (IgG-IgM) and reverse transcriptase-polymerase chain reaction (RT-PCR) for viral RNA in nasopharyngeal swabs are performed. The results of the serologic test are available within minutes. If negative, the patient is granted access to the ward with the RT-PCR result pending. Surgery is only confirmed for the next day once the swab result is negative, usually in the afternoon. If the ELISA rapid test is positive, the patient is sent to a special ward for suspected COVID-19 cases. In these circumstances, patients will only be confirmed for surgery if two consecutive RT-PCR swabs are negative. At any point if the RT-PCR swab is positive or symptoms develop, the patient is sent to a COVID-19 ward and the decision whether to perform surgery is then made by a multidisciplinary team.
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