Radical resection for ampullary carcinoma: long-term results

Laparoscopy-assisted transduodenal papillectomy: how we do it (with video)

BACKGROUND

Some authors previously reported that early ampulla of Vater neoplasms have a low potential of lymph node metastasis and favorable prognosis and, therefore, could be indicated for limited resections instead of the standard pancreatoduodenectomy (PD). In limited resections, when compared to endoscopic papillectomy, transduodenal papillectomy is less technically demanding and a sufficient surgical margin can be achieved due to the greater extent of the excisional area. This didactic video article demonstrated our standardized laparoscopy-assisted transduodenal papillectomy (LATDP).

METHODS

The technique consisted of 3 steps: laparoscopic Kocher mobilization, papillectomy, and reconstruction. This laparoscopy-assisted approach was more favorable than the pure laparoscopic approach as there was no tumor exposure in the abdominal cavity, which might potentially lead to intraabdominal tumor dissemination.

RESULTS

Our LATDP served as a total biopsy to decide whether the subsequent PD was inevitable to patients with early ampulla of Vater neoplasms.

CONCLUSION

This procedure provides the benefit of minimal invasiveness and oncological safety. Therefore, it should be considered as an option in the armamentarium of modern pancreatic and biliary tract surgeries.

Immunophenotyping of ampullary carcinomata allows for stratification of treatment specific subgroups

BACKGROUND

Ampullary carcinomata (AC) can be separated into intestinal (IT) or pancreatobiliary (PB) subtypes. Although morphological, immunohistochemical and molecular differentiation of IT and PB have been well documented; the prognostic significance of histological subtype and whether patients with either subtype benefit from differential chemotherapeutic regimens remains unclear.

METHODS

As part of a larger cohort study, patients who underwent resection for AC or pancreatic ductal adenocarcinoma (PDAC) were retrospectively identified. Clinicopathological covariates and outcome were obtained and MUC1, MUC2, CDX2 and CK20 were assessed with immunohistochemistry.

RESULTS

Of 99 ACs, the resultant immunophenotypes indicated 48% and 22% were IT and PB, respectively. Thirty (30%) cases were quadruple negative (QN). Within the PDAC cohort (N = 257), the most prevalent immunophenotype was QN (53%). Subsequently, all QN ACs were classified as PB immunohistochemically yielding 47.5% and 52.5% classified as IT and PB, respectively. Involved regional lymph nodes and elevated T-stage were significantly associated with PB compared with IT AC (p = 0.0032 and 0.0396, respectively). Progression-free survival revealed inferior survival for PB versus IT AC (p = 0.0156).

CONCLUSIONS

AC can be classified into prognostic groups with unique clinicopathological characteristics using immunohistochemistry. Immunophenotypical similarity of PB and PDAC suggests that treatment regimens similar to those used in PDAC should be explored.

Review of the investigation and surgical management of resectable ampullary adenocarcinoma

BACKGROUND

Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours.

METHODS

A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours.

RESULTS

Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited.

CONCLUSIONS

Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.

Papillary carcinoma of the duodenum combined with right renal carcinoma: a case report

We report a case of papillary carcinoma of the duodenum combined with right renal carcinoma. A 58-year-old man underwent a physical examination that revealed intrahepatic and extrahepatic bile duct dilatation on B ultrasound. Intrahepatic bile duct dilatation could be seen on magnetic resonance imaging (MRI), but the head of the pancreas and distal bile duct showed no tumor signals, which led to a diagnosis of periampullary carcinoma and right renal carcinoma. Considering the trauma of pancreaticoduodenectomy combined with renal resection operation is greater, we carried out the laparoscopic right renal radical resection first, and then a pylorus-preserving pancreaticoduodenectomy was performed. However, postoperative intra-abdominal infections and bleeding occurred; our patient improved after vascular interventional microcoil embolization for the treatment of hemostasis. The second operation for celiac necrotic tissue elimination, jejunal fistulization and peritoneal lavage and drainage was performed 14 days latter. Our patient improved gradually and was discharged on the 58th postoperative day. There has been no tumor recurrence after a follow-up of 26 months.

Surgical outcomes and prognostic factors for ampulla of Vater cancer

BACKGROUND AND AIMS

The prognosis for patients with ampulla of Vater cancer is better than other periampullary cancers. The aim of the present study is to determine the clinicopathologic factors predictive of survival and recurrence in patients with ampulla of Vater cancer.

MATERIAL AND METHODS

From 1991 to 2008, we identified and reviewed 78 patients with ampulla of Vater cancer retrospectively. Clinicopathologic factors possibly influencing survival and recurrence were statistically analyzed.

RESULTS

Pancreaticoduodenectomy was performed in 68 patients and 2 patients underwent transduodenal ampullectomy. Hospital mortality was 2.6%. The 5-year survival rates following resection were 59.9%. Univariate analysis for overall survival revealed that total bilirubin greater than 5 mg/dl, ulcerative tumors, differentiation, and pancreatic invasion were significant prognostic factors. Recurrence occurred in 31 patients. Univariate analysis for disease-free survival revealed that total bilirubin greater than 5mg/dl, preoperative biliary drainage, tumor differentiation, and stage were statistically significant. Multivariate analysis revealed that tumor differentiation was an independent prognostic factor for recurrence. The presence of lymph node metastasis did not affect overall survival significantly in this study. However, two or more metastatic lymph nodes significantly affect disease-free survival.

CONCLUSIONS

Pancreaticoduodenectomy is a safe surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Pancreaticoduodenectomy with lymph node dissection might control lymph node spread and enhance survival outcome.

Factors associated with recidivism following pancreaticoduodenectomy

OBJECTIVES

Factors related to readmission after pancreaticoduodenectomy (PD) may include postoperative morbidity and the functional status of the patient. This study aimed to retrospectively review our institution's experience of readmission of patients who had undergone Whipple procedure PD.

METHODS

Recidivism was defined as readmission to the primary or a secondary hospital within, respectively, 30 days, 30-90 days or 90 days postoperatively. Associations between recidivism, perioperative factors and patient characteristics were evaluated.

RESULTS

During the past 5 years, 30-day, 30-90-day and 90-day recidivism rates were 14.5%, 18.5% and 27.4%, respectively. The most common reasons for readmission included dehydration and/or malnutrition (37.5% of readmissions) and pain (12.5%). Patients who underwent PD for chronic pancreatitis were more likely to be readmitted within 90 days of surgery than patients who underwent PD for malignancy (P < 0.01). Intraoperative transfusion was also associated with 30-90-day and 90-day recidivism (P < 0.01). Preoperative comorbidities, including Charlson Comorbidity Index score, number of pre-discharge complications, type of Whipple reconstruction, preoperative biliary stenting, need for vascular reconstruction and patient body mass index were not associated with recidivism.

CONCLUSIONS

Our data confirm previous reports indicating high rates of readmission after PD. To our knowledge, this report is the first to demonstrate chronic pancreatitis as an independent risk factor for readmission.

Management of ampullary lesions

Adenomatous lesions of the ampulla of Vater are relatively rare neoplasms that raise many questions regarding standard management. Adenocarcinoma often will be found in ampullary lesions and should be treated by pancreaticoduodenectomy (PD). Benign-appearing adenomas may be treated by PD, transduodenal ampullectomy (AMP), or endoscopic ampullectomy (EA). AMP and EA have decreased morbidity and mortality compared with PD but are limited by concerns for appropriate resection margins, high recurrence rates, and the need for surveillance endoscopy or additional procedures. Preoperative endoscopic biopsies should be obtained to identify carcinoma, but they have high false-negative rates and cannot be relied upon to rule out malignancy. Intraoperative frozen section evaluation should be requested routinely during AMP, with conversion to PD if carcinoma is demonstrated. The gold standard management of benign adenomas has not been clarified, but the goal for all treatment modalities is complete resection. Patients with familial adenomatous polyposis may be exceptions to this, and routine surveillance endoscopy and biopsy with selective resection have been advocated by some as an alternative to complete resection. Adjuvant chemoradiation has a very limited role in the treatment of ampullary carcinoma and ideally should be offered in the setting of a clinical trial. Metastatic and locally advanced, unresectable lesions may be palliated by surgical or endoscopic bypass, as well as by celiac plexus blockade.

Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis

BACKGROUND

Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms.

METHODS

Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed.

RESULTS

The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001).

CONCLUSION

When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.

Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis

BACKGROUND

Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms.

METHODS

Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed.

RESULTS

The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001).

CONCLUSION

When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.

Histopathologic features and microsatellite instability of cancers of the papilla of vater and their precursor lesions

The prevalence and development of microsatellite instability (MSI) and underlying mismatch repair (MMR) deficiency in the carcinogenesis of adenocarcinomas of the papilla of Vater and their precursor lesions are not well established. We analyzed 120 ampullary adenomas (31 pure adenomas and 89 carcinoma-associated adenomas) and 170 pure adenocarcinomas for MSI, immunohistochemical expression of MMR proteins and specific histopathologic features. The most common histologic subtype was intestinal (46.5%), followed by pancreatobiliary (23.5%), poorly differentiated adenocarcinomas (12.9%), intestinal-mucinous (8.2%), and invasive papillary carcinomas (5.3%). Eight of 89 adenomas (9%) and 15/144 carcinomas (10%) showed high microsatellite instability (MSI-H), 10/89 adenomas (11%) and 5/144 carcinomas (4%) showed low microsatellite instability (MSI-L), and 71/89 adenomas (80%) and 124/144 carcinomas (86%) were microsatellite stable (MSS). MSI analysis from carcinomas contiguous with an adenomatous component (n=54) exhibited concordant results in 6/8 (75%) MSI-H and 42/46 (91.3%) MSS tumors. Of 14 carcinomas with MSI-H, 7 showed loss of MLH1 and 5/6 (83%) MLH1 promoter methylation, and 2 carcinomas showed simultaneous loss of MSH2 and MSH6. Two carcinomas and 3 adenomas with MSI-H revealed exclusive loss of MSH6. MSI-H cancers were significantly associated with intestinal mucinous subtype (P<0.001), high tumor grade (P=0.003), expansive growth pattern (P=0.044), and marked lymphoid host response (P=0.004). Patients with MSI-H carcinoma had a significantly longer overall survival (P=0.0082) than those with MSI-L or MSS tumors. Our findings indicate that the MSI-phenotype is an early event, which develops at the stage of adenoma and is reliably detectable in the precursor lesion. The MMR deficient molecular pathway of carcinogenesis is associated with a histopathologic phenotype in ampullary cancer, similar to the one that has been well described in colon cancer.

Expression of CD24, P-cadherin and S100A4 in tumors of the ampulla of Vater

Carcinomas of the Vaterian system are rare and presumably arise from preexisting adenomas (adenoma-carcinoma-sequence). Usually, biopsies are obtained to confirm and specify endoscopic findings, but differentiating reactive atypia from dysplasia or dysplasia from invasive carcinoma can sometimes be difficult or even impossible on morphological criteria alone. In case of invasive carcinoma, furthermore, the precise classification of carcinoma subtypes needs to be established since the distinct subtypes differ significantly in terms of clinical outcome. The cell adhesion proteins CD24, P-cadherin and S100A4 were shown to be expressed in several carcinomas and in dysplastic epithelium but only rarely in normal mucosa. We therefore investigated their expression in 177 carcinoma, 114 adenoma and 152 normal mucosa specimens of the ampulla of Vater. Although the expression of the cell adhesion proteins did not differ between the carcinoma subtypes, marked differences between normal mucosa, adenoma and carcinoma samples were observed. All marker proteins were expressed in less than 7% of normal mucosa samples (S100A4 in only 1% of cases) and showed an increasing expression from adenoma to invasive carcinoma. Our findings suggest that P-cadherin and S100A4 are helpful in discriminating normal mucosa or reactive atypia from neoplastic lesions. CD24 and S100A4, furthermore, can assist in the differential diagnosis of dysplasia vs invasive carcinoma.

Immunophenotyping and oncogene amplifications in tumors of the papilla of Vater

Carcinomas of the ampulla of Vater are rare and assumed to generally arise from preexisting adenomas (adenoma-carcinoma sequence). Histologically, distinct subtypes can be distinguished that were shown to differ significantly in terms of clinical outcome. Since pathologists usually receive bioptic tissue samples of ampullary tumors obtained during endoscopy, accurate classification of carcinoma subtypes can sometimes be difficult on morphological criteria alone. We therefore performed immunohistochemistry using a panel of established marker proteins (CK7, CK20, p21, p27, ESA, bax, and ephrin-B2) on 175 carcinoma, 111 adenoma, and 152 normal mucosa specimens of the ampulla of Vater and identified distinct immunoprofiles for every carcinoma subtype. Fluorescence in situ hybridization analyses of therapeutic target genes (c-myc, EGFR1, CCND1, HER2) found CCND1 to represent the most frequently amplified gene in our series (7.5%).

Prognostic impact of perineural invasion following pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma

The aim of this study was to identify prognostic factors in patients undergoing pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma. The records of 46 consecutive patients with ampullary carcinoma who underwent pancreatoduodenectomy from 1988 through 2006 were retrospectively reviewed. A 98% rate of potentially curative (R0) resection was achieved. There was no 30-day mortality. Overall 5-year survival rate was 64%. Univariate analysis revealed that T3 and T4 tumor (i.e., pancreatic parenchymal invasion) (P < 0.001), lymph node metastasis (P = 0.01), and perineural invasion (P < 0.001) were significant predictors of poor prognosis. Furthermore, perineural invasion was found to be a significant independent predictor of poor prognosis by multivariate analysis (P = 0.024). Pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma is a safe surgical procedure with an acceptable cure rate. The presence of perineural invasion may be useful for predicting poor prognosis in patients with ampullary carcinoma who undergo potentially curative resection.

Tumor-related factors and patient's age influence survival after resection for ampullary adenocarcinoma

BACKGROUND/PURPOSE

The majority of surgeons agree that ampullary adenocarcinoma should be removed by partial pancreatoduodenectomy. Favoring extended resection, based on the uncertainty of the preoperative diagnosis and the higher probability of clear resection margins, we aimed to disclose the results of this surgical procedure in terms of postoperative morbidity and mortality, and to identify prognosticators of long-term survival.

METHODS

We documented, prospectively, 25 consecutive patients with adenocarcinoma of the papilla of Vater in whom pylorus-preserving pancreatoduodenectomy was performed. Clinical data, pathology reports, International Union Against Cancer (UICC) tumor stage, postoperative morbidity, mortality, and long-term follow-up results were evaluated. The Kaplan-Meier method and log-rank test were applied for univariate analysis. The Cox proportional hazard model was used for multivariate analysis.

RESULTS

Postoperative mortality was 4%, overall morbidity was 32%, and pancreas-associated morbidity was 8%. Mean survival time was 53.8 months. Tumor size, N status, UICC stage, lymphatic invasion, blood vessel infiltration, R0 resection, and age of patient at the cutoff of 70 years were independent predictors of survival on univariate analysis. Multivariate analysis, however, disclosed no independent predictors of prognosis.

CONCLUSIONS

Pancreatoduodenectomy for ampullary carcinoma is reasonable in terms of postoperative morbidity and mortality. Tumor-related factors, R0 resection, and advanced age appeared as the main predictors of survival.

Synchronous adenocarcinoma of the major and minor duodenal papilla

A 50-year-old woman presented with pancreatitis, fluctuant jaundice, weight loss, and abdominal pain. Contrast-enhanced computed tomography and abdominal ultrasound showed slight dilatation of the biliary tree and gallbladder without calculi. Endoscopy demonstrated a tumor protruding from the papilla of Vater. First endoscopically biopsy diagnosed no tumor, and a second biopsy diagnosed as papillary adenocarcinoma. The patient underwent duodenopancreatectomy. The specimen was fixed in formalin (10%). The tissue was processed routinely, and paraffin sections were stained with hematoxylin-eosin and periodic acid Schiff. Gross examination showed two tumors seen as prolapsed nodules growing isolated from the minor and major duodenal papillae measuring 1.5 and 1.0 cm, respectively, both covered by duodenal mucosa and the histologic study of both lesions demonstrated a moderately differentiated tubular adenocarcinoma, which invaded duodenal wall. After surgery, she is alive 24 months without evidence of recurrence.

Local resection of ampullary tumors

Ampullary tumors are rare. Their appropriate treatment is still contraversial. Local resection of ampullary tumors is a relatively simple procedure with a lower operative morbidity and mortality rate than pancreatoduodenectomy. However, the mortality of Whipple procedure has significantly decreased in the past two decades, as reported in many medical centers. Since accurate preoperative histological diagnosis and staging of the tumors are often difficult and inconclusive, local resection should be limited in those with a poor health status, or in those refusing major operations, although it is considered an alternative in patients with a high co-morbidity.

Review of idiopathic pancreatitis

Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.

Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors

OBJECTIVE

To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC.

PATIENTS AND METHODS

Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended).

RESULTS

The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1-2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018).

CONCLUSION

MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures.

Number of positive lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma

AIM

The nodal status is an established prognostic factor in ampullary carcinoma. The aim of this study was to compare the prognostic power of the anatomic location of positive nodes with that of the number of positive nodes.

METHODS

Of 73 consecutive patients treated for ampullary carcinoma, 62 underwent pancreaticoduodenectomy with regional lymphadenectomy. A survival analysis of these 62 patients by nodal status was conducted retrospectively. A total of 1942 lymph nodes taken from the patients were examined histologically for metastasis. The location of positive regional nodes was classified into 4 categories, according to the Japanese staging system. The number of positive regional nodes was recorded for each patient. The median follow-up period was 124 months.

RESULTS

Nodal disease was found in 31 patients, of whom 23 had 1-3 positive regional nodes and 8 had >or=4 positive regional nodes. Univariate analysis revealed that both the location (p<0.0001) and the number (p<0.0001) of positive nodes were significant prognostic factors. Multivariate analysis revealed that the number of positive nodes was an independent prognostic factor (p=0.007), while the location failed to remain as an independent variable. The median survival time was 59 months with a 5-year survival rate of 48% in patients with 1-3 positive nodes, whereas all patients with >or=4 positive nodes died of the disease within 29 months of resection (p=0.0001).

CONCLUSION

The number, not the location, of positive regional lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma.

Carcinoma of the ampulla of Vater: factors influencing long-term survival of 127 patients with resection

INTRODUCTION

The prognosis for patients with carcinoma of the ampulla of Vater is improved relative to other periampullary neoplasms. Identification of independent prognostic factors in ampullary carcinomas has been limited by the small number of tumors resected. The aim of the present study was to determine the clinicopathologic factors that influence long-term survival in patients with resected ampullary carcinoma.

METHODS

Clinicopathologic data were retrospectively reviewed for patients with ampullary carcinomas radically resected between March 1987 and September 2002. The correlation between clinicopathologic variables and survival of patients after resection was examined by the Kaplan-Meier method, the log-rank test, and Cox proportional hazards regression. Ampullary carcinomas were radically resected in 127 patients either by pancreaticoduodenectomy (n = 124) or local resection (n = 3).

RESULTS

Hospital mortality was 9.7%. The overall actuarial survival rates (including hospital deaths) at 1, 3, 5, and 10 years were 76.2%, 46.8%, 43.3%, and 35.7%, respectively. Factors that significantly influenced survival were lymph node status (P < 0.001), depth of tumor infiltration (P = 0.029), and TNM stage (P < 0.001) on univariate analysis. On multivariate analysis, both depth of infiltration and lymph node status were the independent determinants of survival after resection (P = 0.003, P = 0.005, respectively).

CONCLUSIONS

Carcinoma of the ampulla of Vater has a higher resectability rate and a much better survival rate than pancreatic cancer. Pancreaticoduodenectomy is the treatment of choice for this tumor. Long-term survival was independently influenced by the depth of tumor infiltration and lymph node metastasis.

Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater

BACKGROUND

The prognosis for carcinoma of the ampulla of Vater (CAV) is better than for pancreatic cancer. The 5-year survival median rate after resection of CAV is 45%, but late recurrences remain possible. Several survival factors have been identified (lymph nodes, perineural invasion), but few data are available on the type of recurrences, their impact and their management.

PATIENTS AND METHODS

A total of 41 patients treated by pancreatoduodenectomy (PD) for CAV from 1980 to 2003 were studied retrospectively. Patient selection, long-term survival recurrence rate and recurrence treatment were reviewed. Univariate and multivariate proportional hazards analysis were conducted on this series.

RESULTS

The mean follow-up was 48 months. Five-year survival was 62.8%. Eleven patients had recurrences (6-67 months). Recurrence was associated with time to all-causes death (hazard ratio [HR] 4.3, p=0.003). Factors predictive of recurrence were perineural invasion (HR 5.3, p=0.02), lymph node invasion (HR 5.3, p=0.02) and differentiation (HR 0.2, p=0.05). Three patients underwent surgical R0 treatment of their recurrences. Two who presented with solitary liver metastasis are alive and disease-free.

CONCLUSIONS

Recurrence represents a serious threat in the prognosis of CAV after surgery. Some of these recurrences, in particular liver metastases, are accessible for a curative treatment. This finding supports the usefulness of a close and long-term follow-up after surgery to improve survival of patients with CAV, especially in the group of patients with a good prognosis.

Clinical usefulness of 18-fluorodeoxyglucose positron emission tomography in the management of patients with nonpancreatic periampullary neoplasms

BACKGROUND

18-Fluorodeoxyglucose positron emission tomography (18-FDG PET) has been investigated for the diagnosis and staging of gastrointestinal malignancies including pancreatic adenocarcinoma. The aim of this study was to examine the clinical usefulness of 18-FDG PET in the diagnosis and follow-up evaluation of patients with periampullary neoplasms.

METHODS

Twenty-five patients underwent whole-body 18-FDG PET and abdominal computed tomography (CT). Pathologic confirmation was obtained in all patients by surgical resection or biopsy examination. The 18-FDG PET was analyzed visually and semiquantitatively using the standard uptake value (SUV). Positivity was assumed when a focal uptake occurred with an SUV of 2.5 or greater.

RESULTS

Between January 1998 and December 2003, 14 ampullary, 7 bile duct, and 4 duodenal tumors were included in the study. PET showed increased focal uptake in 22 patients (88%): 11 of 14 (79%) ampullary tumors, and 100% of bile duct and duodenal tumors. PET showed a focal uptake in 11 of 12 patients without detectable mass at CT scan, and lymph node metastases in 6 patients. An SUV value of 2.7 discriminated adenomas or noninvasive cancers (n = 6) from invasive malignancies (n = 14). Follow-up evaluation including CT scan and PET was performed in 12 patients: PET showed recurrent disease not seen by CT in 4 patients, confirmed CT findings in 6 patients, and showed an unsuspected primary lung cancer in 1 patient and colon cancer in another patient.

CONCLUSIONS

18-FDG PET is very sensitive for detecting periampullary neoplasms. It may be useful to differentiate benign or borderline lesions from invasive tumors when no mass has been identified by traditional imaging. Finally, it is very useful in the follow-up evaluation of resected patients to identify recurrent disease or other malignancies.

Long-term survival and recurrence patterns in ampullary cancer

OBJECTIVE

Ampullary cancers are associated with high resectability rates and good long-term survival. However, the small number of patients in various series has hampered survival analysis.

METHODS

One hundred thirteen patients with ampullary cancer underwent pancreaticoduodenectomy between 1989 and 2000, with 48% morbidity and 8% mortality. One hundred four patients who survived the operation were analyzed to identify predictors of long-term survival.

RESULTS

The overall median survival was 30.1 (1.6-140.0) months with actuarial 1-, 3-, and 5-year survival rates of 79%, 43%, and 33%, respectively. Lymph node metastasis (P = 0.002) and vascular invasion (P = 0.008) were 2 independent factors adversely influencing survival. Perioperative blood transfusion (P = 0.001) and vascular invasion (P = 0.026) were important factors predicting recurrent disease.

CONCLUSIONS

Lymph node metastasis and vascular invasion were 2 important factors, which adversely influenced survival in patients with ampullary cancer. Perioperative blood transfusion and vascular invasion were associated with recurrent disease.

Clinical significance of immunohistochemically detectable lymph node metastasis in adenocarcinoma of the ampulla of Vater

BACKGROUND

The aim of this study was to assess the impact of immunohistochemically identified lymph node metastasis on survival in patients with carcinoma of the ampulla of Vater.

METHODS

Three hundred and twenty-six regional lymph nodes dissected from pancreatoduodenectomy specimens from 25 patients with ampulla of Vater carcinoma were immunostained with anticytokeratin antibody (CAM 5.2). The clinicopathological significance of immunohistochemically detectable lymph node metastasis was evaluated and compared with that of other potential prognostic factors.

RESULTS

The frequency of lymph node involvement in relation to the total number of dissected lymph nodes increased from 5.5 per cent (18 of 326) using haematoxylin and eosin staining to 9.5 per cent (31 of 326) using cytokeratin immunostaining (P < 0.001). Lymph node involvement was revealed by haematoxylin and eosin staining in eight of 25 patients and by cytokeratin immunostaining in 11 of 25 patients (P = 0.006). Absence of immunohistochemically detectable lymph node metastasis was identified as an independent predictor of improved postoperative survival.

CONCLUSION

Immunostaining of dissected lymph nodes adds additional information to data obtained by conventional haematoxylin and eosin staining when determining the prognosis of patients with carcinoma of the ampulla of Vater.

Clinicopathologic features of ampullary carcinoma without jaundice

GOALS

To evaluate clinicopathological features of ampullary carcinoma without jaundice.

BACKGROUND

: Obstructive jaundice is the most common symptom of patients with ampullary carcinoma. However, some patients with ampullary carcinoma do not have jaundice at the time of diagnosis.

STUDY

Clinicopathologic findings of 23 patients with ampullary carcinoma showing no visible jaundice (serum total bilirubin <3.0 mg/dL) and 38 patients with ampullary carcinoma showing jaundice at the time of diagnosis were retrospectively compared.

RESULTS

Fifteen of 23 patients with nonjaundiced ampullary carcinoma complained of fever and/or abdominal pain. Five asymptomatic patients were found to have a dilated bile duct on screening ultrasound or to have a tumor-like swelling of the papilla of Vater during routine upper gastrointestinal endoscopy. There was no significant difference in age, sex, size, macroscopic type, histologic type, rates of duodenal invasion, pancreatic invasion, and lymph node metastasis, and prognosis between the two groups. The cumulative 5-year and 10-year survival rates of nonjaundiced patients were 70.2% and 49.0%, compared with 33.6% and 29.4% of jaundiced patients. Ten of the 23 nonjaundiced ampullary carcinomas (43%) were in Stage I, whereas 4 of the 38 jaundiced ampullary carcinomas (11%) were in Stage I (P < 0.01). Mechanisms of nonjaundice in ampullary carcinoma were suspected to be determinant by the infiltrating pattern of the carcinoma to the lower portion of the bile duct.

CONCLUSIONS

Mechanisms of nonjaundice in ampullary carcinoma might be determined by the infiltrating pattern of the carcinoma to the lower portion of the bile. As a greater number of nonjaundiced ampullary carcinomas were in an early stage, detection of them may provide an improved clinical outcome.

Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma

BACKGROUND

Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma.

STUDY DESIGN

We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival.

RESULTS

Forty-three patients (24 men) aged 63.7 +/- 11.4 years (standard deviation) were followed for a mean of 23.9 months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival.

CONCLUSIONS

Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question.

Our local experience with the surgical treatment of ampullary cancer

Background

The aim of this study is to report the outcome after surgical treatment of 32 patients with ampullary cancers from 1990 to 1999.

Methods

Twenty-one of them underwent pancreaticoduodenectomy and 9 local excision of the ampullary lesion. The remaining 2 patients underwent palliative surgery.

Results

When the final histological diagnosis was compared with the preoperative histological finding on biopsy, accurate diagnosis was preoperatively established in 24 patients. The hospital morbidity was 18.8% as 9 complications occurred in 6 patients. Following local excision of the ampullary cancer, the survival rate at 3 and 5 years was 77.7% and 33.3% respectively. Among the patients that underwent Whipple's procedure, the 3-year survival rate was 76.2% and the 5-year survival rate 62%.

Conclusion

In this series, local resection was a safe option in patients with significant co-morbidity or small ampullary tumors less than 2 cm in size, and was associated with satisfactory long-term survival rates.

Pancreatoduodenectomy for tumors of Vater's ampulla: report on 94 consecutive patients

Evaluation of prognostic factors of adenocarcinoma of Vater's ampulla is still a matter of debate. The aim of this study was to evaluate retrospectively factors that influence early and long-term outcomes in a 20-year single-institution experience on ampullary carcinoma. A total of 94 consecutive patients with ampullary carcinoma or adenoma with severe dysplasia were managed from 1981 to 2002. Among them, 64 underwent pancreatoduodenectomy, and the remaining 30 submitted to surgical (n = 5) or endoscopic (n = 25) palliative treatment. Demographic, clinical, and pathologic data were collected, and a comparison was made between patients who did or did not undergo resection. Standard statistical analyses were carried out in an attempt to establish a correlation between clinical variables, intraoperative and pathologic factors, and survival in patients with resection. A total of 85 (90.4%) patients had potentially resectable lesions due to the extent of the tumor, but only 64 (68%) underwent curative resection. The surgical morbidity rate was 34.3%. Postoperative mortality was 9.3%, with no deaths among the 38 more recently treated patients. Median survivals were 9 and 54 months for nonresected and resected patients, respectively. The overall 5-year survival was 64.4% for patients undergoing pancreatoduodenectomy. Survival was found to be significantly affected by resection, tumor size, tumor grade, and tumor infiltration. Patients with negative lymph nodes show a trend toward longer survival. In a multivariate analysis, only the depth of tumor infiltration influenced patient survival. Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma and adenomas with high-grade dysplasia, with a good chance of long-term survival. Surgical resection remains the most important factor influencing outcome.

High-Grade Neuroendocrine Carcinoma of the Ampulla of Vater

We describe the clinical and pathologic features of 14 cases of high-grade neuroendocrine carcinoma (HGNEC) of the ampulla of Vater classified according to WHO classification of lung tumors into small cell carcinoma (SCC, 6 cases) and large cell neuroendocrine carcinoma (LCNEC, 8 cases) types. The immunohistochemical findings were compared with those of 13 cases of primary poorly differentiated ampullary adenocarcinomas (PDACA) lacking neuroendocrine morphology. The mean age of 10 males and 4 females was 70 years. The mean tumor size was 2.5 cm. Ten of 13 patients had lymph node metastases (mean, 2.3 nodes involved). Documented sites of distant metastases included brain and liver. Overall, 64% of patients with ampullary HGNEC died of disease (mean follow-up, 14.5 months). Four patients had no evidence of disease after resection (mean, 20 months). Half of the tumors were associated with adenomas of the adjacent mucosa, 2 with high-grade dysplasia. Two HGNECs were combined with a conventional adenocarcinoma and another with a squamous cell carcinoma component. By immunohistochemistry, the HGNECs were positive for cytokeratins (AE1/AE3, 100%; Cam5.2, 67%; CK7, 87%; CK20, 38%), similar to the pattern found in PDACAs. p27 expression was lost in 1 case of HGNEC and in all PDACAs. Retinoblastoma (Rb) protein expression was lost in 60% of HGNECs and in none of the PDACA cases. In conclusion, HGNECs of the ampulla are rare (2%-3% of ampullary tumors in our material). The clinical course parallels that of their pulmonary counterparts and appears to be worse than that of locally advanced ampullary adenocarcinomas. The association with adenoma and or conventional adenocarcinoma components may suggest a common pathway in the initial carcinogenesis of these two types of tumors. Loss of Rb expression, a characteristic finding in pulmonary SCCs, is present in almost half of ampullary HGNECs. In contrast, p27 expression is lost in PDACAs and retained in most HGNECs. Thus, there are differences in the molecular phenotypes of these two types of ampullary carcinoma, supporting the distinction of poorly differentiated carcinomas with a neuroendocrine phenotype from those without.

Complications of temporary pancreatic stent insertion for pancreaticojejunal anastomosis during pancreaticoduodenectomy

BACKGROUND

Morbidity associated with pancreaticoduodenectomy usually results from complications associated with the pancreaticojejunal anastomosis, in particular, a pancreatic leak. Four patients with retained transanastomotic pancreatic stent-induced complications after pancreaticduodenectomy were identified.

METHODS

Medical records for the 4 patients were reviewed, and telephone interviews were conducted.

OBSERVATIONS

Each patient underwent pancreaticoduodenectomy for a peripapillary tumor with creation of a pancreaticojejunal anastomosis by using an internal 8F Silastic stent. Subsequent evaluation for steatorrhea (n=3) or recurrent pancreatitis (n=1) led to discovery of a retained pancreatic stent. In one patient, the stent was incidentally discovered. Steatorrhea significantly improved (n=1) or resolved (n=2) after stent removal. The patient with pancreatitis has not experienced another episode.

CONCLUSIONS

The possibility of a retained stent should be considered in patients presenting with steatorrhea or pancreatitis after pancreaticoduodenectomy.

Ampullary adenoma: clinical manifestations, diagnosis, and treatment

Ampullary adenomas occur sporadically and in the setting of familial polyposis syndromes. In either case, and whether symptomatic at presentation or found asymptomatically in the setting of endoscopic screening programs, they are premalignant lesions with risk for malignant degeneration to carcinoma following the adenoma-to-carcinoma sequence that is well recognized in colonic adenocarcinoma. Accordingly, many experts advocate excision, although others cite the low rate of histologic progression suggested by some recent studies as justification for close endoscopic surveillance rather than excision before demonstration of dysplastic change. This recommendation, however, is complicated by considerable data underscoring the limited accuracy of endoscopic forceps biopsy in detecting occult foci of carcinoma within ampullary adenoma. Thus, the optimal management of these lesions continues to generate considerable controversy. Indications for excision of an ampullary adenoma include treatment of immediate symptoms as well as prevention of malignant degeneration. Although pancreaticoduodenectomy has long been considered the standard procedure for ampullary carcinoma, much controversy exists regarding the procedure of choice for ampullary adenoma. Radical surgery (pancreaticoduodenectomy) possesses the advantage of low recurrence rate but at the expense of higher morbidity (25%-65%) and mortality (0%-10%). Local surgical excision (surgical ampullectomy) possesses the advantages of lower morbidity (0%-25%), essentially nil mortality, and possibly decreased length of hospital stay, but decidedly higher recurrence rates (generally 5%-30%) and the need for postoperative endoscopic surveillance. Snare ampullectomy is a newer endoscopic excisional technique for which limited data are available; advantages compared with radical surgery mirror those of local surgical excision, with apparent lower mortality (0%-1%) and lower morbidity (12%). Presumed advantages compared with local surgical excision include lack of necessity for general anesthesia and laparotomy with comparable morbidity. Disadvantages seem to include limited availability of experienced operators, procedural complexity sometimes requiring adjunctive modalities such as fulguration, the need for multiple procedures (mean, 2.0 procedures) to effect complete excision, and recurrence rates approaching 30%, with a requirement for continued endoscopic surveillance. Ultimately, choice is driven by availability of local expertise, patient tolerance of or expected compliance with long-term endoscopic surveillance programs, presence or absence of coexisting familial polyposis syndromes, medical comorbidities, and overall life expectancy.

Readmissions after pancreatoduodenectomy

BACKGROUND

Readmission after pancreatoduodenectomy because of tumour recurrence or surgery-related complications can adversely affect patient outcome.

METHODS

From October 1992 to June 1999, 283 consecutive resections were performed (243 for malignant disease and 40 for benign disease). The hospital mortality rate was 1 per cent (three of 283). All readmissions were analysed with regard to indication, treatment and outcome.

RESULTS

One hundred and six patients (38 per cent) were readmitted, 64 (60 per cent) because of tumour recurrence and indications such as gastrointestinal obstruction (n = 19), biliary obstruction (n = 15) and pain (n = 21), of whom 30 patients (47 per cent) were in a preterminal condition. Median hospital stay and hospital-free survival after discharge were 14 and 51 days respectively. Median survival after surgical treatment (n = 14) was 58 days, and ascites was significantly associated with poor survival. Forty-seven (44 per cent) of the patients were readmitted for surgical complications such as abscess (n = 11), fistula (n = 8) and gastrointestinal obstruction (n = 8). Median hospital stay was 15 days and median hospital-free survival after discharge was 1035 days.

CONCLUSION

Readmission after pancreatoduodenectomy was common (38 per cent), 60 per cent for tumour recurrence and 44 per cent for surgery-related complications. Survival after surgical bypass procedures for tumour recurrence was limited, particularly when ascites was present. Patients readmitted for complications of surgery had a good prognosis.

Local resection of ampullary adenocarcinomas of the duodenum

BACKGROUND

Pancreaticoduodenectomy (PD) is considered to be the optimal treatment for ampullary adenocarcinomas. Local resection (LR) is a less invasive and potentially equally effective alternative for cancers with favourable prognostic features. Identification of these prognostic parameters may allow selection of patients suitable for LR.

METHODS

Twenty-five patients were treated for a primary Vater's ampulla adenocarcinoma at the Alfred Hospital, Melbourne, Australia, between January 1989 and January 2000. Risk factors for cancer recurrence were evaluated and the specific role of LR was defined.

RESULTS

Fourteen patients had PD, five had LR and six had bypass procedures (five biliary stents; one operative bypass). Presenting symptoms included jaundice (64%), abdominal pain (54%) and weight loss (32%). Adenocarcinomas that were resected had a median diameter of 2.5 cm, and were limited to the ampulla in 26% (T1), invaded the duodenal wall in 42% (T2) and infiltrated 2 cm or less into the pancreas in 32% (T1) of cases. Locally resected cancers were confined to the ampulla or invaded the duodenum and recurred in one patient following excision. Six recurrences occurred in total, influenced significantly by T staging (P = 0.009). Patient age, preoperative symptoms, laboratory tests, tumour size, differentiation, ulceration, lymphovascular spread and perineural invasion had no effect on recurrence. Patients undergoing LR had lower morbidity and mortality, reduced blood transfusion requirements and shorter hospital stay than those treated by PD.

CONCLUSIONS

T staging predicts the risk of tumour recurrence and can be determined using endoscopic ultrasound. Local resection is a suitable alternative to pancreaticoduodenal resection in patients with T1 and T2 adenocarcinomas with a maximum diameter of 3 cm or less.

Idiopathic acute recurrent pancreatitis

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Outcome of pancreaticoduodenectomy and impact of adjuvant therapy for ampullary carcinomas

PURPOSE

To determine the clinical outcomes and potential impact of adjuvant chemoradiation in patients undergoing surgical resection of ampullary carcinoma.

PATIENTS AND METHODS

Between 1988 and 1997, 39 patients underwent pancreaticoduodenectomy for ampullary adenocarcinomas. Clinical and pathologic factors, adjuvant therapy records, and disease status were obtained from chart review. Thirteen (33%) patients received adjuvant chemoradiation. Radiation therapy was delivered to the surgical bed and regional nodes to a median dose of 4,860 cGy with concurrent bolus or continuous infusion of 5-fluorouracil. Outcomes measures included locoregional control, disease-free survival, and overall survival. Univariate analysis was used to assess the impact of various patient- and tumor-related factors and the use of adjuvant therapy. Twenty (51%) patients with tumor invasion into the pancreas (T3) or node-positive disease were classified in a "high-risk" subgroup.

RESULTS

After a median follow-up of 45 months for survivors, overall 3-year survival was 55%. Survival was significantly worse for patients with positive nodes (23% vs. 73%, p < 0.001) and high-risk status (30% vs. 80%, p = 0.002). Disease-free survival was 54% at 3 years. There were 3 postoperative deaths, and these patients (all high risk) are excluded from further analysis on adjuvant therapy. In univariate analysis, the use of adjuvant chemoradiation had no clear impact on local-regional control or overall survival. However, by controlling for risk status in multivariate analysis, the use of adjuvant therapy reached statistical significance for overall survival (p = 0. 03). Among the high-risk patients, 7 (77%) of 9 patients receiving adjuvant therapy remained disease-free during follow-up compared with only 1 (14%) of 7 patients not receiving adjuvant therapy (p = 0.012).

CONCLUSION

Despite the relatively favorable prognosis of ampullary carcinomas compared with other pancreaticobiliary tumors, patients with nodal metastases or T3 disease are at high risk for disease relapse. The use of adjuvant chemoradiation may improve long-term disease control in these patients.

Pancreaticoduodenectomy for Ampullary Carcinoma

Thirty-two consecutive patients with adenocarcinoma of the ampulla of Vater who had curative resection by pancreaticoduodenectomy were analyzed to determine the accuracy of preoperative investigations and factors that influenced survival. Obstructive jaundice was present in 31 patients, and most patients had pain and weight loss. Ultrasound was more useful than CT in identifying biliary obstruction, whereas CT was more accurate in demonstrating pancreatic duct dilatation and an ampullary mass. Endoscopic retrograde cholangiopancreatography with biopsy and brush cytology was the most accurate investigation and proved or was suspicious of carcinoma in all patients. Nineteen patients had postoperative complications, three of whom died (9.4%)—two of sepsis and one from aspiration following hematemesis. Actuarial 5-year survival was 46 per cent. Stage of disease was the strongest predictor of survival. All patients with T1 lesions are alive more than 5 years after resection. Patients with lymph node metastases had a significantly shorter survival than node-negative patients (P = 0.00087). Pancreaticoduodenectomy is advocated for ampullary carcinoma in good-risk patients, with the anticipation of prolonged survival in those with early (T1) lesions and node-negative disease.

Proximal migration of transanastomotic pancreatic stent following pancreaticoduodenectomy and pancreaticojejunostomy

BACKGROUND

The use of catheters to stent the pancreaticojejunal anastomosis following pancreaticoduodenectomy is practiced by some surgeons. Their long-term effects in this setting, however, remain unknown.

METHODS

A 60-yr-old woman underwent a potentially curative pylorus preserving pancreaticoduodenectomy for Stage I ampullary carcinoma. Roux-en-Y pancreaticojejunostomy was constructed over a short stent. She presented 4 yr later with abdominal pain, steatorrhea, and weight loss. Computed tomography revealed a stent within the proximal pancreatic duct, with gross upstream ductal dilatation and parenchymal features of chronic pancreatitis.

RESULTS

Laparotomy revealed no disease recurrence. The stent, removed through a jejunotomy, was occluded. On-table pancreatogram demonstrated a 3-cm proximal duct stricture. Drainage was achieved with a lateral pancreaticojejunostomy (modified Puestow procedure). Recovery was uneventful, with clinical recovery of pancreatic exocrine function at 6 mo follow-up.

CONCLUSION

Proximal migration of transanastomotic pancreatic stent with subsequent development of chronic pancreatitis is a potential complication following pancreaticoduodenectomy. It can be managed effectively with stent removal and a lateral pancreaticojejunostomy.

Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study

BACKGROUND

An adenoma-carcinoma sequence also applies to adenomas of the major duodenal papilla. Therefore accurate preoperative diagnosis and tumor staging are essential to select the appropriate patients for adequate treatment. In a prospective, histopathologically controlled study of tumors of the main duodenal papilla, the preoperative diagnostic value of ultrasound (US) catheter probes applied during endoscopic retrograde cholangiopancreatography (ERCP) was investigated.

METHODS

Intraductal US was compared with conventional endoscopic ultrasonography (EUS) and computed tomography (CT). In 27 consecutive patients with benign polypoid tumors of the major duodenal papilla (n = 12) and carcinomas of the papilla (n = 15), respectively, the value of these imaging procedures in determining tumor visualization, tumor diagnosis and tumor staging according to the TNM classification was assessed. Every patient underwent surgical resection; histopathologic evaluation of resected specimens served as the reference standard.

RESULTS

Intraductal US was significantly superior to EUS and CT in terms of tumor visualization (100% vs 59.3% vs 29.6%, respectively). Sensitivity and specificity rates for intraductal US and EUS were 100% versus 62.5% and 75% versus 50%, respectively. Overall accuracy rate in tumor diagnosis for intraductal US (88.9%; 24 of 27) was significantly (p = 0.05) superior to EUS (56.3%; 9 of 16). The latter did not depict 4 adenomas and 7 carcinomas. Neither intraductal US nor EUS is suitable for detection of distant metastases.

CONCLUSION

Intraductal US appears to be the most effective imaging method in visualizing, diagnosing and staging tumors of the major duodenal papilla. Combining ERCP with catheter probe sonography offers a new diagnostic modality that has some potential advantages for local staging of small tumors of the main duodenal papilla. Consequently, minimally invasive techniques for resection of seemingly benign tumors of the papilla or, even more so, of small carcinomas should preferably be based on intraductal US.

[Malignant tumors of the ampulla of Vater. Results of radical excision. A study of 39 cases]

STUDY AIM

From 1971 to 1995, 39 patients underwent curative resection of a malignant tumor of the ampulla of Vater. The aim of this retrospective study was to report long-term results and to determine factors influencing survival in these patients.

PATIENTS AND METHODS

Data was collected from patient record analysis, correspondence with patients, their family or general physician. Kaplan-Meier method was used to compare survival data by the log-rank test. Multivariate analysis evaluated the impact of each variable on survival. Values with a P value of 0.05 or less were considered statistically significant.

RESULTS

Resection consisted of pylorus preserving pancreaticoduodenectomy (n = 21) or pancreatico-duodenectomy associated with an antrectomy (n = 18). Overall mortality rate after resection was 10% (n = 4). General and specific morbidity rates were 71% and 2.5%. During the course of the follow-up (completeness: 100%) mean survival was 80 months (median: 37 months, range: 6-227 months). Five-year survival rate was 35%. Factors favorably influencing long-term outcome were exposed protruding and well differentiated tumors (P = 0.03, P = 0.01, respectively) and negative lymph node status (P = 0.0001). Prognosis was poorer if tumor was extended into the pancreas (P = 0.04). Among proposed histoprognostic classifications (classifications of Martin, Talbot, Shiraï, Yamaguchi), an excellent correlation was obtained only with TNM classification (P = 0.0001).

CONCLUSION

Results of the present study suggest that prolonged survival can be obtained following radical resection of a malignant tumor of the ampulla of Vater, especially for exposed protruding and well differentiated tumors, without extension into the pancreas or lymph node metastasis. TNM classification provides an excellent predictive value and should be used more systematically.

The use of endoscopic ultrasonography to reduce the cost of treating ampullary tumors

BACKGROUND

Local excision of selected ampullary tumors may result in the same benefit as Whipple resection with less morbidity and mortality. The purpose of this study was to determine if endoscopic ultrasonography could aid in the selection of patients for local resection and to determine if there was a significant cost difference between the two surgical procedures.

METHODS

In this retrospective study of 32 patients who underwent surgery for ampullary tumors, endoscopic ultrasonography staging was performed in 18 patients. Resected specimens were used to determine pathologic staging. Local disease was defined as stage T2N0 or less. Cost data were available for 20 patients.

RESULTS

The sensitivity and specificity of endoscopic ultrasonography for differentiating local from advanced ampullary tumors were both 83%. The median total cost for a local resection was $9314 versus $16,017 for a Whipple resection (p < 0.0017).

CONCLUSION

Endoscopic ultrasonography is an effective tool for identifying patients with localized ampullary tumors. The cost of a local resection for ampullary tumors is significantly less than that of a Whipple resection. The use of endoscopic ultrasonography to select patients for local resection may be a cost-effective technique in the management of patients with ampullary tumors.

Adenocarcinoma of the ampulla of Vater. A 28-year experience

OBJECTIVE

The aim of this study were to review the experience with adenocarcinoma of the ampulla of Vater at The Johns Hopkins Hospital and to determine what factors influenced the long-term outcome in these patients.

SUMMARY BACKGROUND DATA

Adenocarcinoma of the ampulla of Vater is the second most common periampullary malignancy. However, most series have relatively small numbers. As a result, analysis of factors influencing outcome has been limited.

METHODS

From 1969 to 1996, 120 patients with adenocarcinoma of the ampulla of Vater were managed at The Johns Hopkins Hospital. Clinical, operative, and pathologic factors were correlated with morbidity and long-term survival. Factors influencing outcome were evaluated by univariate and multivariate analyses.

RESULTS

Resection was performed in 106 patients (88%), and 105 of these patients (99%) underwent either pancreatoduodenal resection (n = 103) or total pancreatectomy (n = 2). Resection rate increased from 62% in the 1970s to 82% in the 1980s to 96% in the 1990s (p < 0.05). Overall mortality after resection was 3.8% with no mortality in the 45 consecutive patients resected in the past 5 years. Morbidity also decreased significantly (p < 0.05) from 70% before to 38% after December 1992. Five-year survival for resected patient was 38%. Factors favorably influencing long-term outcome were resection (p < 0.001), no perioperative blood transfusions (p < 0.05), negative lymph node status (p = 0.05), and moderate or well-differentiated tumors (p < 0.05). In a multivariate analysis, the best predictor of prolonged survival was absence of intraoperative transfusion (p = 0.06, relative risk = 1.90, 95% confidence limits = 0.95-3.78).

CONCLUSIONS

Compared to carcinoma of the pancreas, carcinoma of the ampulla of Vater has a higher resectability rate and a better prognosis. Early diagnosis is important because lymph node status influences survival. Careful operative dissection and avoidance of transfusions also improves long-term survival.

Obstructive jaundice resulting from adenocarcinoma of the ampulla of Vater in an 11-year-old boy

Adenocarcinoma of ampulla of Vater causing obstructive jaundice in an 11-year-old boy is reported. He first underwent pylorus-preserving duodenectomy, which later necessitated classical Whipple operation because of the microscopical evidence of the disease beyond surgical margins. This child is the youngest case of adenocarcinoma of ampulla of Vater in the English-language literature.

Carcinoma of the ampulla of Vater: is radical lymphadenectomy beneficial to patients with nodal disease?

This study was undertaken to evaluate the effectiveness of radical lymphadenectomy in ampullary cancer with nodal disease. Thirty-five patients underwent the Whipple procedure with radical lymphadenectomy. The location and number of positive nodes was characterized. Eighteen patients (51%) had positive nodes. Patients without nodal disease (pN0 group) had an actuarial 5-year survival rate of 81%. Seven patients with metastasis confined to the pancreaticoduodenal nodes had a 5-year survival rate of 67%, which was comparable for the pN0 group (N.S.) and better than the 27% 5-year survival rate in patients with positive superior mesenteric nodes (P<0.05). Eleven patients with one to three positive nodes had a 5-year survival rate of 71%, which was also comparable to the pN0 group (N.S.) and better than the 0% 5-year survival rate in patients with four or more positive nodes (P<0.01). Radical lymphadenectomy is effective against a limited degree of nodal disease.