Lecture : Although pancreaticoduodenectomy (PD) has been standard treatment for ampullary cancers, transduodenal ampullectomy (TDA) as a less invasive procedure has been attempted for early stage cancer due to high morbidity after PD. For local resection of the ampulla to be an alternative surgical treatment of PD for early ampullary cancer, morbidity of the procedure and operative curability should be taken into consideration. First, the morbidity advantage of TDA over PD in patients with standard surgical risk is less than previously reported. With the improvement of surgical technique and perioperative care, complication rates after PD have been improved, especially when operation is performed in high volume centers. On the other hand, morbidity of TDA was reported to be high in studies comparing adverse events after surgical and endoscopic ampullectomy. Second, several studies reported that TDA was associated with higher local recurrence rate than PD in the patients with T1 ampullary cancer. The data supporting the oncologic safety of ampullectomy, conversely, are scarce and based on a limited number of patients. LN metastasis is not exceptional in T1 ampullary cancer with a frequency ranging from 10 to 50% and also CBD or P-duct mucosal involvement is not rare. Although lymph node dissection can be performed during ampullectomy, it would be difficult to complete lymph node dissection including nodes around the superior mesenteric artery, where is one of frequent sites for LN metastasis of ampullary cancer. Moreover, preoperative diagnostic modalities and intraoperative frozen biopsy may not be able to accurately predict the presence or extent of mucosal tumor infiltration into the CBD or P-duct. Therefore, PD should be preferably performed for adequate radical resection, even in early ampullary cancer, and ampullectomy should be reserved for patients with a high surgical risk.