Medico

AMPULLA OF VATER Anatomic, Embryologic, and Surgical Aspects
Surgical Clinics of North America - Volume 80, Issue 1 (February 2000)  -  Copyright © 2000 W. B. Saunders Company  -  About This Journal | |[pic]

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SURGICAL ANATOMY AND EMBRYOLOGY

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AMPULLA OF VATER
Anatomic, Embryologic, and Surgical Aspects





Claude Avisse MD
Jean-Bernard Flament MD
Jean-FrancoisDelattre MD

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Department of Anatomy, University of Reims; and Department of Digestive Surgery, Hopital Robert Debre, Reims, France
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Address reprint requests to
Claude Avisse, MD
Department of Digestive Surgery
Hopital Robert Debre
Rue du General Koenig
51092 Reims Cedex
France


The ampulla of Vater (i.e., the hepatopancreatic ampulla) corresponds anatomically with the dilatedjunction of the common bile duct and the main pancreatic duct of Wirsung before their opening into the duodenum. This ampullary appearance is inconstant, and its existence is disputed by some investigators.


Considered more widely and realistically from the surgical viewpoint, the ampulla of Vater constitutes the junction of the biliary, pancreatic, and digestive tracts (Fig. 1) . Itcorresponds to an anatomic and functional region that comprises (1) the junction of the common bile duct and pancreatic duct; (2) surrounded by the sphincteric system of Oddi; (3) traversing a dehiscence of the duodenal wall (fenestra choledochae); and (4) terminating at the greater duodenal papilla (or great caruncle), covered by the duodenal mucosa. The ampulla of Vater is the site of tumors, oftenwith a threatening prognosis and the surgical treatment of which may be consequently difficult. It is also commonly the site of disorders specific to or caused by the neighboring organs that affect biliopancreatic emptying. The understanding of these disorders has benefited from peroperative manometric studies and from endoscopy. Numerous anatomic, embryologic, pathophysiologic, and pathologicstudies of the ampulla of Vater have been performed. This article reviews only important and practical points of these studies.





CHOLEDOCHOPANCREATIC JUNCTION


The junction of the main pancreatic duct and the common bile duct and their opening at the greater duodenal papilla (Fig. 2) occurs in three ways [6] : (1)

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Figure 1. Junction of the biliary, pancreatic,and digestive tracts (peroperative cholangiogram).



a common duct, 1 mm to 8 mm in length, in 60% of cases; (2) a "double-barreled" opening at the apex of the papilla in 38% of cases; and (3) separate duodenal openings for the two canals in 2% of cases. In 1720, Vater [6] noted this junctional arrangement of the bile and pancreatic ducts; after having ligated the papillary orifice andinjecting water into the common bile duct, he noted a reflux of fluid into the duct of Wirsung, which became expanded at the duodenal wall as a tubercle, which he called the diverticulum of the bile. The studies of Soemmering [6] in 1801 and of Bernard [6] in 1856 established this concept of a common duct dilated into an ampulla, the so-called ampulla of Vater. Of 50 anatomic specimens studied,Papalmitiades and Rettori [7] found such a common duct in only 31 cases (62%), and observed a dilatation of this common duct, justifying the term ampulla in only 2 cases (4%), so the existence of this structure is disputed, and many investigators consider it as merely an artifact of anatomic dissection.

The site of duodenal implantation of this ductal junction and the association of the mainpancreatic duct of Wirsung with the common bile duct are important to consider. In 75% of cases, the greater duodenal papilla, with the two ducts, is implanted in the descending portion of the duodenum (see Fig. 2 ) at the junction of its posterior and medial aspects, high up but usually at its midportion. The terminal pancreatic duct is always inferior and anterior to the common bile duct ( Fig. 3 A)....