Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma

Preoperative Immunonutrition and Postoperative Outcomes in Radical Pancreaticoduodenectomy Patients

BACKGROUND/AIMS

This study aimed to compare the patient groups who received and did not receive immunonutrition in terms of mortality and morbidity in patients who underwent radical pancreaticoduodenectomy.

MATERIALS AND METHODS

Two groups were formed from 40 patients who underwent radical pancreaticoduodenectomy in our clinic in 2021. The patients in study group were given enteral immunonutrition support for 5 days preoperatively. For this purpose, a standard enteral immunonutrition product containing arginine, omega-3 fatty acids, and RNA (dietary nucleotides) was used. Patients' data of demographical, laboratory, postoperative complications, and current clinical status were analyzed.

RESULT

Mortality developed in 5 (25 %) patients in the treatment group and 4 (20 %) patients in the control group in the following months (P > .05). The estimated survival rate in the treatment group was 21.8 ± 2.8 months in the treatment group 19.1 ± 1.7 months in the control group (P > .05). The length of hospital stay was 12.89 ± 3.3 days in the treatment group, while it was 16.47 ± 6.83 days in the control group (P < .05). In the postoperative follow-ups, delayed gastric emptying symptoms developed in 3 patients in the treatment group, while the same complication was observed in 9 patients in the control group (P < .05). Surgical site infections occurred in 4 patients in the treatment group and 9 patients in the control group (P < .05).

CONCLUSION

It was observed that preoperative oral immunonutrition before pancreaticoduodenectomy was effective in reducing the risk of delayed gastric emptying after surgery and the length of hospital stay.

Metachronous primary colon and periampullary duodenal cancer: A case report

RATIONALE

Primary periampullary duodenal cancer accounts for 3% to 17% of periampullary cancers. There are no previous reports of metachronous primary colon and periampullary duodenal cancer.

PATIENT CONCERNS

We present a case of primary periampullary duodenal cancer that occurred metachronously after colon cancer.

DIAGNOSES

Imaging and endoscopic examinations, serum tumor marker levels, and pathology confirmed metachronous colon and periampullary duodenal cancer, with 14-month interval between the diagnoses of the 2 malignancies.

INTERVENTION

The patient received right hemicolectomy combined with mFOLFOX6 chemotherapy for colon cancer and pancreatoduodenectomy for periampullary duodenal cancer.

OUTCOMES

The patient has been followed up for 6 years since the pancreatoduodenectomy and shows no signs of recurrence or metastasis.

LESSONS

The risk of developing a second malignancy may be associated with the site of the first tumor. Patients with right colon cancer may have particularly high risk of developing small intestinal cancer, including duodenal cancer. Early detection and active surgical treatments can improve prognosis. Long-term regular follow-up is necessary to detect new malignancies occurring after the diagnosis colon cancer.

Factors affecting survival in patients who underwent pancreaticoduodenectomy for periampullary cancers

OBJECTIVE

The purpose of this study was to determine the factors affecting survival in patients who underwent pancreaticoduodenectomy for periampullary cancers and to discuss the outcomes of our findings.

MATERIAL AND METHODS

This retrospective study included 79 patients who underwent pancreaticoduodenectomy for periampullary cancers between September 1987 and October 2011 in the Department of General Surgery at Ondokuz Mayis University School of Medicine. The factors of age, tumor localization, tumor size, lymphovascular invasion, status of lymph node metastasis, tumor differentiation, preoperative CA 19-9 levels, preoperative total bilirubin levels, preoperative albumin levels, and preoperative biliary drainage were investigated to determine their influence on survival. The survival periods were calculated using the Kaplan-Meier method. The log-rank test was used for comparison of the prognostic factors. The independent prognostic factors affecting survival were determined by Cox hazard regression analysis and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. P<0.05 was considered as significant.

RESULTS

The following were identified as independent prognostic factors adversely affecting survival: tumor size ≥2 cm (HR: 2.0, 95% CI: 0.27-0.90), lymphovascular invasion (HR: 2.9, 95% CI: 0.18-0.60), CA 19-9 levels ≥100 U/mL (HR: 2.0, 95% CI: 0.26-0.90), and albumin levels <2.5 mg/dL (HR: 2.7, 95% CI: 1.14-6.66).

CONCLUSION

The independent prognostic factors identified in this study can be used for selection of patients for whom pancreaticoduodenectomy should be applied for periampullary cancers. These factors could help us to estimate survival rates.

Comparative yield of fine needle aspiration cytology, ampullary biopsy, and needle knife assisted biopsy in the diagnosis of nonulcerated periampullary tumors

AIM

Periampullary tumors (PAT) are defined as tumors arising within 2 cm of the major duodenal papilla. Studies on yield of preoperative biopsy for nonulcerated PAT are scarce. Needle knife papillotomy-assisted biopsy (NKAB) may sample the deeper tissues and thereby increase the histologic yield. We aimed to compare the diagnostic yield of fine needle aspiration cytology (FNAC), surface ampullary biopsy, and NKAB in nonulcerated PAT.

METHODS

Patients with suspected PAT based on clinical, biochemical, and radiologic investigations were evaluated. Patients with smooth ampullary bulge on side viewing endoscopy (SVE) were included, while those with gastric outlet obstruction or obvious ulceration of ampulla on SVE were excluded.

RESULTS

Twenty-five of 78 patients with PAT met the inclusion criteria. The median (range) age was 60 (43-75) years, and 13 were male. Serum CA 19.9 was 466 (2-9372) U/mL. Histopathological positivity rate for surface biopsy, FNAC, and NKAB was 10 (40 % and 95 % CI: 21.8 % to 61.1 %), 12 (48 % and 95 % CI: 28.3 % to 68.2 %), and 21 (84 % and 95 % CI: 63.1 % to 94.7 %), respectively. Diagnostic yield of NKAB was significantly better than surface biopsy (p = 0.001) and FNAC (p = 0.007). None of the patients subjected to NKAB had any complications other than self-limited minor ooze.

CONCLUSION

NKAB was superior to surface biopsy or FNAC to establish preoperative tissue diagnosis of nonulcerated PAT. NKAB is safe and simple in expert hands and may be recommended as standard procedure to obtain histological specimen in these patients.

Interobserver agreement for confocal imaging of ampullary lesions: a multicenter single-blinded study

BACKGROUND

Malignant ampullary lesions can be difficult to classify by endoscopy alone. Probe-based confocal laser endomicroscopy (pCLE) permits in vivo assessment of mucosal structures in the gastrointestinal tracts in the real time.

AIM

The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of pCLE of ampullary lesions.

METHODS

Twelve pCLE video clips of ampullary lesions were distributed to 6 gastrointestinal specialists at 5 medical centers, blinded to final pathologic results. Six variables were assessed for interobserver agreement using κ statistics. Variables included an epithelial outer border with irregular thickness, dark epithelium without discernable individual cells, heterogenously distributed elongated crypts, reduced number of goblet cells, neovascularization, and final diagnosis.

RESULTS

The overall interobserver agreement for all observers was poor to slight for all variables (κ=0.02, 0.05, -0.01, 0.04, 0.018) except for the first variable with fair degree of agreement (κ=0.27). On the basis of experience, 3 observers were classified as less experienced, whereas 3 were classified as most experienced. Upon stratification, the less experienced observers had poor interobserver agreement for all variables, except 1. The most experienced observers had poor agreement for 2 variables, slight agreement for 3 variables, and fair agreement for the final diagnosis variable.

CONCLUSIONS

The overall interpersonal agreement on pCLE for ampullary lesions was poor. The interobserver agreement was not substantially improved for experienced raters. Further standardization of pCLE image criteria is needed for ampullary lesions. Standardized training may improve interrater reliability to an acceptable level.