Carcinoma of the papilla of Vater. Diagnostic and surgical problems

Background/Aims: Although carcinoma of the Vater's papilla is a well-recognized tumor, difficulties and misdiagnosis are still encountered in the early and on-time diagnostic process. Methodology: Thirty-six patients with tumors of the papilla of Vater, hospitalized in the 2nd Department of Surgery (1981-2000) were reviewed retrospectively. Results: Twenty-two men and 14 women, age varied from 39 to 84 years. Papilla tumor was defined as any neoplastic lesion, located at the papilla of Vater region. According to gross appearance of the tumor there were 12 pts with polypoid type without ulceration; 10 pts - polypoid type with ulceration and 14 pts - ulcer formation type. The most common presenting signs and symptoms included: jaundice - 94.4%; weight loss - 86%; abdominal pain - 64%; nausea/vomiting - 47%; pruritus - 50%. The classic triad of jaundice, palpable gallbladder and anemia with occult gastrointestinal bleeding was not present in all cases. Most valuable for the exact diagnosis were ultra-sonography, computed tomography scan and careful endoscopic examination of the periampullary region before and after endoscopic retrograde cholangiopancreatography, with biopsy of any abnormal appearance. Local resection was done in 7 pts (predominantly polypoid type) with tumor size ranging 1.8-2.2cm. Pancreatoduodenal resection was performed in 8 pts (Whipple procedure in 5 and Pylorus preserving in 3). By-pass procedure was performed in 21 pts. Biliodigestive anastomosis done alone in 14 and biliodigestive anastomosis + gastroenterostomy in 7 pts. Most commonly performed biliodigestive anastomosis was hepatico/choledocho-duodenostomy - 14; hepatico-jejunostomy - 6 and cholecystogastrostomy one patient. Postoperative morbidity - 18% and postoperative mortality - 2 pts. Conclusions: Carcinoma of the papilla of Vater is a rare gastrointestinal malignancy. Tumor size, gross appearance, biopsy material, lymph node metastases and UICC stage have a significant impact on the operative stratergy and postoperative result.