Ampullary Tumours- Endoscopic Resection, Local Surgery or Pancreatoduodenectomy: BJS Open | August 2026

Introduction:

Choosing treatment for ampullary tumours requires balancing oncological completeness against procedural morbidity. Endoscopic resection (ER) is increasingly used for benign lesions; transduodenal ampullectomy (TDA) offers a surgical organ-preserving alternative, while pancreatoduodenectomy (PD) remains the oncological standard for invasive malignancy. This meta-analysis of 80 studies compared complete resection, recurrence and complications across these three approaches.

Why was this study needed?

Ampullary tumours are rare, limiting prospective comparative evidence.

Preoperative distinction between adenoma, early carcinoma and invasive cancer can be difficult.

ER and TDA avoid the morbidity of PD but may compromise oncological clearance.

The role of local therapy for Tis/T1 ampullary carcinoma remains particularly controversial.

Results:

Complete resection

ER: highly variable, 29–100%

TDA:

Benign/early-stage: 90%

Malignant: 66%

PD:

Benign/early-stage: 99%

Malignant: 97%

Recurrence in benign/early-stage disease

ER: 12%

TDA: 12%

PD: 6%

For malignant tumours, recurrence after TDA was highly heterogeneous (48–90%), whereas the pooled recurrence rate after PD was 16%.

Complication rates were heterogeneous—9–95% with ER, 32% with TDA, and 27–98% with PD.

Clinical Impact:

The findings support a treatment hierarchy based primarily on tumour biology and oncological risk:

Benign, endoscopically resectable lesion → ER

Benign lesion unsuitable for ER → selected TDA

Invasive ampullary carcinoma → PD generally remains the oncological reference

The major concern with local treatment of apparently early carcinoma is not simply achieving local clearance. Occult lymph-node disease cannot be addressed by ER or TDA, and preoperative staging may underestimate invasive disease.

The Key Unmet Need: Better Preoperative Diagnosis

The study highlights that the central challenge may be patient selection rather than technique.

If clinicians could reliably distinguish:

Adenoma → Tis → T1 with/without nodal risk → more advanced carcinoma

the least invasive treatment capable of maintaining oncological adequacy could be selected more confidently.

This is particularly important because proceeding directly to PD for a benign lesion may represent overtreatment, whereas performing local resection for an inadequately staged carcinoma risks undertreatment.

Caution:

This is not a randomised comparison of the three treatments. The 80 included studies were heterogeneous, with substantial variation in patient selection, tumour stage, technique and outcome reporting.

Patients undergoing PD are also fundamentally different from those selected for ER or TDA. Therefore, the pooled numbers should not be interpreted as direct evidence that one procedure is superior to another for the same patient.

Bottom Line:

For ampullary tumours, treatment should follow oncological risk rather than procedural simplicity. ER is an appropriate minimally invasive strategy for selected benign lesions; TDA has a narrower organ-preserving role; and PD provides the most reliable complete resection and oncological control for malignant disease. The biggest remaining challenge is accurate preoperative discrimination between benign and invasive disease.