title: [Letter from a reader].
abstract: OBJECTIVE
  Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection.
  
  
  METHODS
  Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention.
  
  
  METHODS
  The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed.
  
  
  CONCLUSIONS
  Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.
authors.forename: Christian
authors.initials: C
authors.lastname: Schmidt
mesh_terms: D000550:Amblyopia / Q000175:diagnosis*; D003519:Cyclopentolate; D005260:Female; D006801:Humans; D008297:Male; D009184:Mydriatics; D012029:Refraction, Ocular; D042261:Retinoscopes; D012815:Signal Processing, Computer-Assisted / Q000295:instrumentation*; D014787:Vision Tests / Q000295:instrumentation*
chemical_list: D009184:Mydriatics; D003519:Cyclopentolate