Local resection of ampullary adenocarcinomas of the duodenum

Impact of biliary stents in the performance of the EUS-guided tissue acquisition: A systematic review and meta-analysis

INTRODUCTION AND AIM

Pancreatobiliary tumours are challenging to diagnose exclusively by imaging methods. Although the optimum moment for carrying out the EUS is not well defined, it has been suggested that the presence of biliary stents may interfere with the proper staging of tumours and the acquisition of samples. We performed a meta-analysis to evaluate the impact of biliary stents on EUS-guided tissue acquisition yield.

MATERIAL AND METHODS

We conducted a systematic review in different databases, such as PubMed, Cochrane, Medline, and OVID Database. A search was made of all studies published up to February 2022.

RESULTS

Eight studies were analyzed. A total of 3185 patients were included. The mean age was 66.9±2.7 years; 55.4% were male gender. Overall, 1761 patients (55.3%) underwent EUS guided tissue acquisition (EUS-TA) with stents in situ, whereas 1424 patients (44.7%) underwent EUS-TA without stents. The technical success was similar in both groups (EUS-TA with stents: 88% vs EUS-TA without stents: 88%, OR=0.92 [95% CI 0.55-1.56]). The type of stent, the needle size and the number of the passes were similar in both groups.

CONCLUSIONS

EUS-TA has similar diagnostic performance and technical success in patients with or without stents. The type of stent (SEMS or plastic) does not seem to influence the diagnostic performance of EUS-TA. Future prospectives and RCT studies are needed to strengthen these conclusions.

Surgical ampullectomy: A comprehensive review

Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system. They are typically diagnosed at an earlier stage than other types of tumours in this region, due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct. Consequently, many are potentially curable by excision. Surgical ampullectomy (SA) (or transduodenal ampullectomy) for an ampullary tumour was first described in 1899, but was soon surpassed by pancreatoduodenectomy (PD), which offered a more extensive resection resulting in a lower risk of recurrence. Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy (EP), particularly for adenomas and even early cancers. The vast majority of resectable ampullary tumours are now treated using either PD or EP. However, SA continues to play a role in specific circumstances. Many authors have suggested specific indications for SA based on their own data, practices, or interpretations of the literature. However, certain issues have attracted controversy, such as its use for early ampullary cancers. Consequently, there has been a lack of clarity regarding indications for SA, and no evidence-based consensus guidelines have been produced. All studies reporting SA have employed observational designs, and have been heterogeneous in their methodologies. Accordingly, characteristics of patients and their tumours have differed substantially across treatment groups. Therefore, meaningful comparisons of clinical outcomes between SA, PD and EP have been elusive. Nevertheless, it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival, hence its role in this setting warrants further clarification, while it can also be useful in the management of specific benign entities. Whilst the commissioning of a randomised controlled trial seems unlikely, well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA, potentially informing the eventual development of consensus guidelines. In this comprehensive review, we explore the role of SA in the modern management of ampullary lesions.

FLUCTUATING JAUNDICE IN THE ADENOCARCINOMA OF THE AMPULLA OF VATER: a classic sign or an exception?

BACKGROUND

Some authors consider the fluctuating jaundice as a classic sign of the adenocarcinoma of the ampulla of Vater.

OBJECTIVE

Assessing the frequency of fluctuating jaundice in their forms of its depiction in the patients with adenocarcinoma of the ampulla of Vater.

METHODS

Observational and retrospective study, conducted through analyses of medical records from patients subjected to pancreatic cephalic resections between February 2008 and July 2013. The pathological examination of the surgical specimen was positive to adenocarcinoma of the ampulla of Vater. Concepts and differences on clinical and laboratory fluctuating jaundice were standardized. It was subdivided into type A and type B laboratory fluctuating jaundice.

RESULTS

Twenty patients were selected. One of them always remained anicteric, 11 patients developed progressive jaundice, 2 of them developed clinical and laboratory fluctuating jaundice, 5 presented only laboratory fluctuating jaundice and one did not present significant variations on total serum bilirubin levels. Among the seven patients with fluctuating jaundice, two were classified as type A, one as type B and four were not classified due to lack information. Finally, progressive jaundice was the prevailing presentation form in these patients (11 cases).

CONCLUSION

This series of cases suggested that clinical fluctuating jaundice is a uncommon signal in adenocarcinoma of the ampulla of Vater.

Long-term prognosis of surgical treatment for early ampullary cancers and implications for local ampullectomy

Background

Early ampullary cancers present with good prognosis. Pancreaticoduodenectomy (PD) has been standard treatment for ampullary cancers, but it remains high rate of postoperative complications. So there raises a discussion on the role of local ampullectomy for early ampullary cancers (mainly focusing on pT1).

Methods

89 patients with pT1 ampullary cancer who underwent surgical treatment between 1978 and 2010 were retrospectively studied.

Results

Rate of postoperative complications, especially post-operative pancreatic fistula (P = 0.009), after PD was higher than after local ampullectomy, . Multivariate analysis showed that tumor size (HR 2.204; P = 0.014), lymph node metastasis (HR 4.362; P < 0.001), lymph vascular invasion (HR 4.258; P < 0.001), and perineural invasion (HR 4.467; P < 0.001), gross morphology (HR 2.536; P = 0.004) and tumor grade (HR 4.213; P = 0.001) were independent risk factors for long-term survival, as well as risk factors for failure of ampullectomy in early ampullary cancer. For patients absent of these factors, local ampullectomy would achieve a good prognosis.

Conclusions

Because of high rate of lymph node metastasis, PD should be preferably performed for radical resection. Local ampullectomy could be an alternative for patients in high operative risk; and would achieve a good outcome in patients whose tumors were well differentiated and showed polypoid gross morphology and size ≤1 cm.

Is local resection adequate for T1 stage ampullary cancer?

BACKGROUND

Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD.

METHODS

All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared.

RESULTS

There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05-0.61, P < 0.005] or a PD (HR 0.23; 95% CI 0.15-0.36, P < 0.001).

CONCLUSION

Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.

Recent advances in diagnosis and treatment of primary duodenal tumors

Compared to tumors from other parts of the gastrointestinal tract, primary tumors of the duodenum are uncommon. Both benign tumors and malignancies are possible, although the majority are malignancies. The treatment of choice is surgical resection, mostly pancreaticoduodenectomy. With the development of endoscopy microsurgery and medical imaging technology, especially the advent of gastroduodenal fiberscopy, capsule endoscopy, endoscopic ultrasonography (EUS), endoscopic retrograde cholangio-pancreatography (ERCP) and laparoscopy, more duodenal neoplasms have been detected in recent years. Some advances have been achieved in the diagnosis and treatment of duodenal tumors. Endoscopic and segmental resections play a more and more important role in the management of duodenal tumors. In this paper, we describe the clinical features, pathological patterns, diagnosis and treatment of primary duodenal tumors.

Prognostic factors for survival of patients with ampullary carcinoma after local resection

BACKGROUND

Local resection (LR) is a potentially effective alternative to pancreaticoduodenectomy for treatment of ampullary cancer, but the prognostic factors remain undefined. The purpose of this study was to identify the prognostic factors for ampullary cancer patients who had undergone LR.

METHODS

We retrospectively reviewed the clinical, pathological data and surgical approach of 34 ampullary cancer patients who had undergone LR during 1996-2009 at People's Liberation Army General Hospital. Prognostic factors for survival and recurrence were analysed.

RESULTS

The 1-, 3- and 5-year survival rates of the patients were 97.1, 69.5 and 53.7%, respectively. The gender, age, preoperative bilirubin levels, CA19-9 levels and preoperative biopsy did not correlate with the survival rates. The survival rates of patient with T1 and T2 tumours were superior to that of patients with T3 tumours (P = 0.000). Tumour size, surgical margin status and the extent of differentiation had no effect on survival rates (P = 0.464, P = 0.601 and P = 0.121, respectively). The survival rate of patients who had extraduodenal LR (12 cases) was superior to that of patients who had transduodenal LR (22 cases) (P = 0.026). Tumour recurrence occurred in 14 (41.2%) patients. Tumour infiltration (P = 0.014) correlated with the recurrence.

CONCLUSION

The degree of tumour infiltration is the pathological factor that most affects the survival of ampullary cancer patients who undergo LR. Extraduodenal LR is a promising surgical procedure, the efficacy of which is superior to that of transduodenal LR. The depth of tumour invasion correlated with the recurrence.

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.

Comparison between two types of local resection in the treatment of ampullary cancer

BACKGROUND

This study aims to compare the effects of two different local resection procedures on the prognosis of ampullary cancer.

METHODS

We carried out a retrospective study using clinical and pathological data from patients with ampullary cancer who underwent local resection between February 1996 and February 2009 in the PLA General Hospital. In these participants, we carried out a comparative analysis between the transduodenal (the transduodenal group) and the extraduodenal (extraduodenal group) surgical approaches.

RESULTS

No significant differences in gender, age, preoperative bilirubin levels, CA19-9 values, biopsy results, tumour size, differentiation status, degree of invasion, surgical margins, recurrence, metastasis and complication rates, and intraoperative blood loss were found. As compared to the transduodenal group, the extraduodenal group showed a longer duration of surgery and higher survival rates.

CONCLUSIONS

Even though the operation time for the extraduodenal resection of ampullary cancer was longer, the survival rate was higher than in patients who underwent transduodenal resection. For certain patients, the extraduodenal approach may be more appropriate when technical conditions allow it.

Laparoscopic transduodenal ampullectomy for benign ampullary tumors

INTRODUCTION

Transduodenal ampullectomy (TDA) can be performed for benign and premalignant tumors of the ampulla of Vater (AOV) as an alternative to pancreaticoduodenectomy. However, the laparoscopic approach has rarely been attempted. In this report 2 cases of benign ampullary tumor that were treated by totally laparoscopic TDA.

PATIENTS AND METHODS

Case 1 was of a 75-year-old female who was admitted with left knee pain and underwent arthroscopic debridement. On postoperative day 6, she showed elevated levels of alkaline phosphatase, aspirate aminotransferase, alanine transaminase, and gamma-glutamyl transpeptidase, without any other laboratory test abnormality. She had no complaint of abdominal pain, and physical examinations were unremarkable. Computed tomography (CT), magnetic resonance cholangiography (MRCP), and endoscopy revealed a 2-cm-sized polypoid mass at the AOV. Subsequent endoscopic biopsy showed a pathologic finding of tubular adenoma. Case 2 was of a 55-year-old man who was admitted with an duodenal mass incidentally detected by screening endoscopy in a community hospital. Abdominal CT, endoscopy, and endoscopic ultrasonography revealed a 2.5-cm-sized tumor located at the duodenal papilla with possible extension to the ampullary sphincter. Endoscopic biopsy revealed gangliocytic paraganglioma. Both patients underwent laparoscopic transduodenal ampullectomy.

RESULTS

Operative times were 200 and 250 minutes, respectively, and estimated blood loss during both operations was about 50 mL. Patients were discharged on the postoperative days 9 and 8, respectively, without any complication. Postoperative histologic examinations revealed tubular adenoma with low-grade dysplasia in 1 patient and gangliocystic paraganglioma in the other.

CONCLUSIONS

These 2 cases demonstrate that laparoscopic TDA is a feasible operative procedure in selective patients with a benign or premalignant tumor at the AOV.

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.

Ampullary tumors: endoscopic versus operative management

Most ampullary adenomas (80%) are common benign ampullary tumors; however, they can range from mild dysplasia to high-grade dysplasia to invasive carcinoma. They are considered premalignant lesions found in the setting of familial polyposis syndromes or found sporadically, usually manifested by vague abdominal pain, liver enzyme elevation, jaundice, recurrent pancreatitis, or with uncommon symptoms such as gastrointestinal bleeding or duodenal obstruction. Endoscopic retrograde cholangiopancreatography with biopsy is a minimally invasive technique used to visualize these tumors directly and to evaluate their histologic characteristics. Definitive treatment primarily depends on these histologic results. Local resection has a high rate of recurrence (5% to 30%) and requires postoperative endoscopic surveillance, which is the reason it is not considered as a first choice in the management of ampullary tumors. The operative mortality is 10% or less for pancreaticoduodenectomy, a procedure of choice at most experienced centers for frank carcinoma, foci papillary adenocarcinoma in pre-excisional biopsies, or high-grade dysplasia ampullary adenomas. Endoscopic interventions for presumed benign ampullary adenomas have resolved symptoms of obstruction, but long-term follow up is necessary to detect early malignant transformation. In summary, the choice of treatment depends on level of surgical skill available, patient tolerance of long-term endoscopic surveillance versus radical surgery, and the presence or absence of coexisting familial adenomatous polyposis.