Live surgeryApril 29, 20231:52:367 speakersAvailable in: EN / IT
ICG-School Clinical Round: Laparoscopic Ampullectomy for Villous Adenoma of the Ampulla of Vater
ICG-School Clinical Round on a villous adenoma of the ampulla of Vater in an elderly cardiac patient: laparoscopic surgical ampullectomy with ICG marking and management of postoperative leak.
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Clinical case
Adenoma tubulo-villoso della papilla di Vater con displasia ad alto grado focale (uT1N0)
Patient framing as discussed at case introduction
SexMaschio
Age78 anni
StageuT1N0 - lesione confinata a mucosa/sottomucosa
DiagnosisAdenoma tubulo-villoso della papilla di Vater con displasia ad alto grado focale (uT1N0)
Prior treatmentRadioterapia e ormonoterapia per Ca prostatico; PTCA con stent medicato
Clinical historySovrappeso (BMI 28), diabete, ipertensione, neoplasia prostatica trattata con radioterapia e ormonoterapia. IMA recente (2 mesi prima) con PTCA e stent medicato in doppia antiaggregazione. ECOG 0-1, Karnofsky 80-90. Anemia microcitica ipocromica come sintomo d'esordio.
NotesCaso non in live surgery ma re-live commentata; lesione di 5-6 cm sulla parete mediale del duodeno dal ginocchio superiore alla terza porzione, coinvolgente la papilla.
Overview
Sixth Clinical Round of the Permanent School on ICG Surgery, dedicated to surgery of the ampulla of Vater. Gian Luca Baiocchi presents a case operated in Cremona: a 78-year-old man, with cardiac comorbidity on dual antiplatelet therapy after a recent myocardial infarction with drug-eluting stent, carrier of a bulky tubulo-villous adenoma (5-6 cm) of the medial duodenal wall involving the papilla, discovered during workup for microcytic anemia. The discussion involves two senior experts – Tullio Piardi (Troyes, French school of minimally invasive HPB surgery) and Fabrizio Romano (Bicocca/San Gerardo Monza) – and four residents from the Brescia and Siena schools.
The debate addresses every decisional crossroad in a structured way: management of dual antiplatelet therapy, role of CT, MR cholangiography and endoscopic ultrasound with deep biopsies, choice between endoscopic ampullectomy (referring to the experience of Donatelli and the European Pancreas Club), surgical ampullectomy and pancreaticoduodenectomy, advantages/risks of laparoscopic vs open approach, trocar placement and the right-lateral access suggested by Piardi for the Kocher maneuver. Indocyanine green is injected endoscopically into the polyp the day before, elegantly marking the extrahepatic biliary tree and the tumor site during surgery.
The technical steps of laparoscopic ampullectomy are shown, with introduction of a hydrophilic guidewire through the cystic duct as a landmark for the papilla, longitudinal duodenotomy, excision of the polyp, management of the difficulties in reconstructing the bile duct and Wirsung duct on a thin posterior pancreas. Transpapillary biliary drainage, jejunostomy, the option of gastro-jejunal anastomosis and duodenal exclusion are discussed. The course is complicated by a duodenal leak on postoperative day 6, managed conservatively with discharge on day 18; histology confirms tubulo-villous adenoma with focal high-grade dysplasia and clear margins. The case becomes an opportunity for a frank comparison between Italian and French schools on the relevance of ampullectomy in the toolkit of the HPB surgeon.
Topics
Indications for surgical ampullectomy vs PD vs endoscopic ampullectomy
Role of endoscopic ultrasound and deep biopsies in periampullary lesions
Endoscopic ICG marking for lymph nodes and bile duct
Minimally invasive laparoscopic approach to the ampulla of Vater
Bile duct and Wirsung duct reconstruction after ampullectomy
Management of postoperative duodenal leak
Veress vs Hasson comparison in laparoscopic access
Use of ICG in HPB surgery (HCC, metastases, liver cysts, biliary tree)
