The role of mesopancreas excision for ampullary carcinomas: a single center propensity-score matched analysis

Resection Margin Status and Long-Term Outcomes after Pancreaticoduodenectomy for Ductal Adenocarcinoma: A Tertiary Referral Center Analysis

The influencing role of resection margin (R) status on long-term outcomes, namely overall (OS) and disease-free survival (DFS), after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is not still clear. The aim of this study is to evaluate the prognostic impact of R status after PD and to define tumor characteristics associated with a positive resection margin (R1). All PDs for PDAC performed between 2012 and 2023 were retrospectively enrolled. The effect of R status, patient clinico-demographic features, and tumor features on OS and DFS were assessed. One-hundred and sixty-seven patients who underwent PD for PDAC were included in the study. R0 was achieved in 105 cases (62.8%), while R1 was evidenced in 62 patients (37.1%). R1 was associated with a decreased OS (23 (13-38) months) as compared to R0 (36 (21-53) months) (p = 0.003). Similarly, DFS was shorter in R1 patients (10 (6-25) months) as compared to the R0 cohort (18 (9-70) months) (p = 0.004), with a consequent higher recurrence rate in cases of R1 (74.2% vs. 64.8% in the R0 group; p = 0.04). In the multivariate analysis, R1 and positive lymph nodes (N+) were the only independent influencing factors for OS (OR: 1.6; 95% CI: 1-2.5; p = 0.03 and OR: 1.7; 95% CI: 1-2.8; p = 0.04) and DFS (OR: 1.5; 95% CI: 1-2.1; p = 0.04 and OR: 1.8; 95% CI: 1.1-2.7; p = 0.009). Among 111 patients with N+ disease, R1 was associated with a significantly decreased DFS (10 (8-11) months) as compared to R0N+ patients (16 (11-21) months) (p = 0.05). In conclusion, the achievement of a negative resection margin is associated with survival benefits, particularly in cases of N1 disease. In addition, R0 was recognized as an independent prognostic feature for both OS and DFS. This further outlines the relevant role of radical surgery on long-term outcomes.

Anomalies of the right hepatic artery in periampullary cancer treatment: are pathological and clinical outcomes different? A single tertiary referral center retrospective analysis

PURPOSE

Anomalies of the right hepatic artery (RHA) may represent an additional challenge in pancreatoduodenectomy (PD). The aim of this study is to assess the potential impact of variations in hepatic arterial anatomy on perioperative outcomes.

METHODS

PDs performed for periampullary malignancies between 2017 and 2022 were retrospectively enrolled and subdivided in two groups: modal pattern of vascularization (MPV) and anomalous pattern of vascularization (APV). A propensity score matching (PSM) analysis was conducted to homogenize the two study populations. The two groups were then compared in terms of perioperative outcomes and pathological findings.

RESULTS

Thirty-eight patients (16.3%) out of 232 presented a vascular anomaly: an accessory RHA in 7 cases (3%), a replaced RHA in 26 cases (11.2%), and a replaced HA in 5 cases (2.1%). After PSM, 76 MPV patients were compared to the 38 APV patients. The incidence rate of postoperative complications was comparable between the two study populations (p=0.2). Similarly, no difference was detected in terms of histopathological data, including margin status. No difference was noted in terms of intraoperative hemorrhage and vascular resection.

CONCLUSION

When PDs are performed in high-volume centers, the presence of an APV of the RHA does not relate to a significant impact on perioperative complications. Moreover, no influence was noted on histopathological findings.

The Impact of Post-Pancreatectomy Acute Pancreatitis (PPAP) on Long-Term Outcomes after Pancreaticoduodenectomy: A Single-Center Propensity-Score-Matched Analysis According to the International Study Group of Pancreatic Surgery (ISGPS) Definition

Post-pancreatectomy acute pancreatitis (PPAP) is a potentially life-threating complication. Although multiple authors demonstrated PPAP as a predisposing feature for a more detrimental clinical course, no evidence is currently present on its potential impact on long-term outcomes. The aim of this study is to evaluate how PPAP onset may influence overall (OS) and disease-free survival (DSF) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Patients who underwent PD for PDAC from 2006 to 2021 were enrolled. PPAP was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definition. Propensity score matching (PSM) was performed in order to reduce potential selection biases. After PSM, 32 patients out of 231 PDs who developed PPAP (PPAP group) were matched to 32 patients who did not present PPAP (no-PPAP group). PPAP patients more frequently presented major post-operative complications (p = 0.02) and post-operative pancreatic fistula (POPF) (p = 0.003). Median follow-up was 26.2 months, with no difference between the two groups (p = 0.79). A comparable rate of local or distant metastases was noted in the two cohorts (p = 0.2). Five-year OS was comparable between the two populations (39.3% and 35.7% for the no-PPAP and PPAP populations, respectively; p = 0.53). Conversely, despite not being statistically significant, a worse 5-year DFS was evidenced in the case of PPAP (23.2%) as compared to the absence of PPAP (37.4%) (p = 0.51). With the limitations due to the small sample size, PPAP may potentially relate to worse long-term outcomes in terms of DFS. However, further studies with wider study populations are still needed in order to better clarify the prognostic role of PPAP.

Acute pancreatitis after pancreatoduodenectomy: clinical outcomes and predictive factors analysis according to the International Study Group of Pancreatic Surgery definition

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP.

METHODS

Patients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria.

RESULTS

Among 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48-76.1%vs118-25.8%; p < 0.0001), delayed gastric emptying (DGE) (27-42.9%vd114-24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57-90.5%vs186-40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01).

CONCLUSION

The ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.

The impact of the histological classification of ampullary carcinomas on long-term outcomes after pancreaticoduodenectomy: a single tertiary referral center evaluation

PURPOSE

Ampullary carcinomas (ACs) are classified as pancreatobiliary (Pb-AC), intestinal (Int-AC), or mixed (Mixed-AC). The influencing role of AC subtypes on long-term outcomes is still matter of debate. Aim of this study is to evaluate the prognostic role of the three histological variants on the overall (OS) and disease-free survival (DFS) after pancreaticoduodenectomy(PD).

METHODS

All PDs for AC between 2004 and 2020 were included. Patients were classified according to the histological feature in Pb-AC, Int-AC, and Mixed-AC. Five-year OS and DFS were compared among the subtypes. Additionally, the prognostic role of the histological classification on OS and DFS was evaluated.

RESULTS

Fifty-six (48.7%) Pb-ACs, 53 (46.1%) Int-ACs, and 6 (5.2%) Mixed-ACs were evaluated. A poorer 5-year OS was evidenced for the Pb-AC group (54.1%) as compared to the Int-AC cohort (80.7%) (p = 0.03), but similar to the Mixed-AC population (33%) (p = 0.45). Pb-AC presented a worse 5-year DFS (42.3%) in comparison to the Int-AC (74.8%) (p = 0.002), while no difference was evidenced in comparison to the Mixed-AC (16.7%) (p = 0.51). At the multivariate analysis, the Pb-/Mixed-AC histotype was recognized as negative prognostic factor for both OS (OR: 2.29, CI: 1.05-4.98; p = 0.04) and DFS (OR: 2.17, CI: 1-4.33; p = 0.02).

CONCLUSION

Histological subtypes of AC play a relevant role in long-term outcomes after PD. Pb-ACs and Mixed-ACs show a more aggressive tumor biology and a consequent worse survival as compared to the Int-AC subtype.

Das Ampullenkarzinom – prognostische und therapeutische Unterschiede zum duktalen Adenokarzinom des Pankreas

Das Ampullenkarzinom stellt eine seltene, jedoch in seiner Inzidenz steigende Entität gastrointestinaler Tumoren dar. Aufgrund der anatomischen Lokalisation führt es vergleichsweise früh im Erkrankungsprozess zu einer biliären Gangobstruktion, wodurch eine schnellere Diagnosestellung erleichtert und eine bessere Prognose bedingt werden. Adenome der Ampulla hepatopancreatica und der Papilla duodeni major stellen Vorläuferläsionen des Ampullenkarzinoms dar und besitzen ein 30–40%iges Risiko zur malignen Transformation. Diese Entartungstendenz begründet die Notwendigkeit zur vollständigen/kompletten Abtragung im Rahmen der endoskopischen Therapie. Der Erfolg der endoskopischen Papillektomie wird durch eine Ausdehnung des Befundes in den Pankreashauptgang oder Ductus choledochus erschwert. Endoskopisch nicht sanierbare Adenome und Ampullenkarzinome stellen Indikationen für chirurgische Therapieverfahren dar. Grundsätzlich sollte für benigne Befunde die transduodenale Papillenresektion bervorzugt werden, für maligne Befunde stellt die Pankreaskopfresektion mit systematischer Lymphadenektomie und Level-II-Dissektion des Mesopankreas die onkologisch korrekte Operation dar. Prognostische Faktoren beim Ampullenkarzinom sind: der pankreatobiliäre Subtyp, eine Lymphknoteninfiltration und eine Perineuralscheideninvasion. Die Differenzierung in histopathologische Subtypen gewinnt zunehmend in der Indikationsstellung zur Systemtherapie an Bedeutung. Der Einsatz der neoadjuvanten und adjuvanten Therapie für das Ampullenkarzinom konnte bisher nicht klar definiert werden. Jedoch scheinen Patienten mit dem pankreatobiliären Subtyp oder anderen prognoselimitierenden Faktoren von einer adjuvanten Therapie zu profitieren. Zukünftige Studien werden zur zielgerichteten Therapiefestlegung benötigt.

Survival after curative pancreaticoduodenectomy for ampullary adenocarcinoma in a South American population: A retrospective cohort study

BACKGROUND

Ampullary adenocarcinoma (AAC) is a rare neoplasm that accounts for only 0.2% of all gastrointestinal cancers. Its incidence rate is lower than 6 cases per million people. Different prognostic factors have been described for AAC and are associated with a wide range of survival rates. However, these studies have been exclusively conducted in patients originating from Asian, European, and North American countries.

AIM

To evaluate the histopathologic predictors of overall survival (OS) in South American patients with AAC treated with curative pancreaticoduodenectomy (PD).

METHODS

We analyzed retrospective data from 83 AAC patients who underwent curative (R0) PD at the National Cancer Institute of Peru between January 2010 and October 2020 to identify histopathologic predictors of OS.

RESULTS

Sixty-nine percent of patients had developed intestinal-type AAC (69%), 23% had pancreatobiliary-type AAC, and 8% had other subtypes. Forty-one percent of patients were classified as Stage I, according to the AJCC 8th Edition. Recurrence occurred primarily in the liver (n = 8), peritoneum (n = 4), and lung (n = 4). Statistical analyses indicated that T3 tumour stage [hazard ratio (HR) of 6.4, 95% confidence interval (CI) of 2.5-16.3, P < 0.001], lymph node metastasis (HR: 4.5, 95%CI: 1.8-11.3, P = 0.001), and pancreatobiliary type (HR: 2.7, 95%CI: 1.2-6.2, P = 0.025) were independent predictors of OS.

CONCLUSION

Extended tumour stage (T3), pancreatobiliary type, and positive lymph node metastasis represent independent predictors of a lower OS rate in South American AAC patients who underwent curative PD.