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

Intraperitoneal hyaline vascular Castleman disease: Three case reports

BACKGROUND

Castleman disease (CD) was first reported in 1954. It is a rare non-malignant lymphoproliferative disease with unclear etiology. As the clinical manifestations of CD are different, there are difficulties in its diagnosis and treatment. Therefore, for patients with CD, it is important to establish the diagnosis in order to choose the appropriate treatment.

CASE SUMMARY

In this report, three patients with intraperitoneal CD treated at our center from January 2018 to June 2023 were reviewed, and the clinical and paraclinical examinations, diagnosis, and treatment were analyzed, and all three patients were diagnosed with CD by routine histopathological and immunohistochemical examinations.

CONCLUSION

CD is a complex and rare disease. Because there are no special clinical symptoms and laboratory abnormalities, the diagnosis often depends on routine pathological and immunohistochemical findings.

Long-term Outcomes of Endoscopic Intraductal Radiofrequency Ablation for Ampullary Adenoma with Intraductal Extension after Endoscopic Snare Papillectomy

Background/Aims

There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension.

Methods

Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated.

Results

A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of ID-RFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures.

Conclusions

Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Long-term recurrence after endoscopic versus surgical ampullectomy of sporadic ampullary adenomas: a systematic review and meta-analysis

BACKGROUND AND AIMS

Ampullary adenomas are treated both surgically and endoscopically, however, data comparing both techniques are lacking. We aimed to compare long-term recurrence of benign sporadic adenomas after endoscopic (EA) and surgical ampullectomy (SA).

METHODS

A comprehensive literature search of multiple databases (until December 29, 2020) was performed to identify studies reporting outcomes of EA or SA of benign sporadic ampullary adenomas. The outcome was recurrence rate at 1 year, 2-year, 3 year and 5 years after EA and SA.

RESULTS

A total of 39 studies with 1753 patients (1468 EA [age 61.1 ± 4.0 years, size 16.1 ± 4.0 mm], 285 SA [mean age 61.6 ± 4.48 years, size 22.7 ± 5.4 mm]) were included in the analysis. At year 1, pooled recurrence rate of EA was 13.0% (95% confidence interval [CI] 10.5-15.9], I² = 31%) as compared to SA 14.1% (95% CI 9.5-20.3 I² = 15.8%) (p = 0.82). Two (12.5%, [95% CI, 8.9-17.2] vs. 14.3 [95% CI, 9.1-21.6], p = 0.63), three (13.3%, [95% CI, 7.3-21.6] vs. 12.9 [95% CI, 7.3-21.6], p = 0.94) and 5 years (15.7%, [95% CI, 7.8-29.1] vs. 17.6% [95% CI, 6.2-40.8], p = 0.85) recurrence rate were comparable after EA and SA. On meta-regression, age, size of lesion or enbloc and complete resection were not significant predictors of recurrence.

CONCLUSION

EA and SA of sporadic adenomas have similar recurrence rates at 1, 2, 3 and 5 years of follow up.

The Future Perspectives of Redefining the Resection Margin Status in Different Cancers of Pancreas

Background: The interest towards the assessment of circumferential resection margins(CRM) in pancreatic cancers has been evolving over last years. Whilst several studies investigated the influence of R1-resections on survival, not many studies evaluated the prognostic value of each resection margin. In this study, we examined the different resection margins to better understand their prognostic implications on overall survival. Methods: This prospective study included a cohort of patients who had pancreaticoduodenectomy for cancer purposes at our institution from 2008 till 2013. Median follow-up was 6 years. Involved margins in R1-resections were further classified into anatomical margins (anterior, posterior and circumferential margins) and surgical margins (vascular/medial margins and transection margins). Overall survival was assessed for each specific resection margin. Results: 134 patients were included with median age 66 years. R1-resection was done in 54% of patients(n=72/134). Median survival of R0-resection group was 6.3 years, compared to 1.9 years for R1-resection group(p-value 0.001). Vascular (surgical) margins had the lowest survival rate (1.7years) compared to anatomical margins (anterior, posterior and circumferential margins) with 3.6, 2.2 and 2.1 years respectively (p-value 0.02). On multivariate analysis; lymph node involvement and vascular resection were the only factors to correlate significantly with poor survival. Conclusion: Whilst the new pathological protocols advised to perform rigorous margin assessment of CRM, the prognostic value of each resection margin is still unclear. This study  showed variation of survival across different resection margins with inferiority towards vascular (surgical) margins. This supported the need of redefining R1-margins in the future pathological classifications according to their different prognostic impacts.

Proposal of a new T-stage classification system for ampullary carcinoma based on Surveillance, Epidemiology and End Result (SEER) database

BACKGROUND

Tumor size is still considered a useful prognostic factor in currently available tumor-node-metastasis (TNM) classification staging systems for most solid tumors, but the significance of tumor size on the prognosis of ampullary carcinoma remains controversial. The aim of the current study was to propose a new T-stage classification system for ampullary carcinoma to address the impact of tumor size on the prognostic outcome.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 1080 patients with ampullary carcinoma who underwent radical surgical resection between 2004 and 2015. Based on the results obtained from analysis of various clinicopathologic factors, a new T-stage classification system was proposed.

RESULTS

Among the 1080 patients, 618 were men and 462 were women, with a median tumor size of 2.3 (range 0.1-12) cm. Using the 7th edition of the American Joint Committee on Cancer (AJCC) staging manual, we noticed significant differences in overall survival (OS) between T2 vs. T3 tumors (P < 0.001) and T3 vs. T4 tumors (P = 0.002), but failed to observe significant differences between T1 vs. T2 tumors (P = 0.498) in our pair-wise comparison. Using the newly developed T-stage classification system, we were able to differentiate significant differences in OS between T1 vs. T2 tumors (P = 0.032), T2 vs. T3 tumors (P < 0.001) and T3 vs. T4 tumor (P = 0.003) in all pair-wise comparisons. The c-index of the new staging system was 0.653 (95% CI: 0.629-0.677), showing a better discriminatory power than the 0.636 of the 7th AJCC staging system (95% CI: 0.612-0.660).

CONCLUSIONS

The new T-stage classification system described herein can better differentiate prognostic outcomes after radical resection in patients with ampullary carcinoma by incorporating tumor size and depth of tumor infiltration.

Preoperative 2-[18F]FDG PET-CT aids in the prognostic stratification for patients with primary ampullary carcinoma

OBJECTIVES

We sought to investigate whether preoperative dual-phase 2-[¹⁸F]FDG PET-CT identify predictors for poor survival in patients with ampullary carcinoma receiving pancreaticoduodenectomy.

METHODS

The preoperative PET-CT images of patients with resected ampullary carcinoma from June 2007 to July 2017 were analyzed. Survival curves were analyzed using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazard model was used to identify potential prognostic factors associated with disease-free survival (DFS) and overall survival (OS).

RESULTS

Fifty-four subjects (26 men, 28 women) were enrolled with a median tumor size of 20 mm. All patients were followed for a median period of 36.9 months with 3- and 5-year DFS of 50.3% and 44.2%, and OS of 77.0% and 68.2%, respectively. Parameters associated with DFS in multivariate analysis were lymphovascular invasion (hazard ratio [HR]: 9.45, p < 0.001), involved margin in pathology (HR: 7.67, p < 0.001), and tumor retention index (RI) from the dual-phase PET (HR: 2.41, p = 0.03), whereas involved margin (HR: 13.14, p < 0.001), post-recurrence chemotherapy (HR: 0.10, p < 0.001), and metabolic tumor volume (MTV) (HR: 4.62, p = 0.009) emerged as independent prognostic factors for OS.

CONCLUSIONS

Preoperative 2-[¹⁸F]FDG PET-CT offered independent prognostic biomarkers in patients with ampullary carcinoma receiving standard surgical resection.

KEY POINTS

• 2-[¹⁸F]FDG PET-CT offers good survival prediction before operation in primary malignant neoplasms at ampulla of Vater. • Dual-phase PET scan with bowel distention can better delineate Ampulla of Vater and characterize tumor physiology. • Preoperative risk stratification might aid in better treatment planning.

The Safety of Radiofrequency Ablation Using a Novel Temperature-Controlled Probe for the Treatment of Residual Intraductal Lesions after Endoscopic Papillectomy

BACKGROUND/AIMS

Treatment of residual intraductal lesions after endoscopic papillectomy for ampullary adenomas is relatively difficult. Few studies have been conducted using intraductal radiofrequency ablation (RFA) in the treatment of such lesions, and no study has aimed to reduce the side effects of excessive heat caused by RFA. Recently, a temperature-controlled RFA probe was developed to avoid excessive heat. This study aimed to investigate the safety of this new RFA probe in the treatment of intraductal lesions of ampullary adenoma.

METHODS

Patients who received RFA for residual intraductal lesions after endoscopic papillectomy between November 2017 and June 2019 were retrospectively reviewed. A novel temperature- controlled probe (ELRA) was used for intraductal RFA, and clinical data including adverse events were collected.

RESULTS

Ten patients were included in this study. Intraductal adenomas showed low-grade dysplasia in eight patients and high-grade dysplasia in two patients. The median diameter of intraductal adenomas was 9 mm (range, 5 to 10 mm) in the common bile duct and 5 mm (range, 4 to 11 mm) in the pancreatic duct. Adverse events occurred in three patients (30.0%), of which two were mild pancreatitis and one was asymptomatic biliary stricture. Over a median follow-up period of 253 days, only one patient underwent additional surgery, as the remainder showed no adenomatous lesions on follow-up biopsies.

CONCLUSIONS

The new temperature-controlled RFA probe can be used with acceptable safety for the treatment of residual intraductal lesions after endoscopic papillectomy. Further evaluation through future prospective studies is needed.

Transduodenal surgical ampullectomy: a procedure that requires a multidisciplinary approach

Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180-390), mean tumor size was 2.3 cm (range 1.5-3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1-96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8-60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.

Incidental hepatic tuberculosis during planned resection of locally advanced ampullary carcinoma: a case report

Background

Tuberculosis (TB) is classified according to the site of disease as pulmonary or extrapulmonary. Extrapulmonary TB is less common than its counterpart in which it can be found anywhere in the body including the liver. Similar to ampullary carcinoma, TB liver can manifest with jaundice and deranged liver function tests, particularly in the obstructed biliary systems.

Case presentation

A 43-year-old gentleman with locally advanced ampullary carcinoma was noticed to have multiple suspicious liver nodules intraoperatively during curative ampulla resection. The surgery was then abandoned after a biopsy. The histology was consistent with chronic granulomatous inflammation. He was then subjected to a Whipple pancreaticoduodenectomy procedure after initiation of anti-tubercular treatment. He recovered well with no evidence of tumour recurrence and worsening TB.

Conclusions

A high index of suspicion and quick decision making can help to diagnose a possible extrapulmonary TB masquerading as a malignant disease in a patient with curative intention of ampullary carcinoma.

Prognostic factors and benefits of adjuvant therapy for ampullary cancer following pancreatoduodenectomy: A systematic review and meta-analysis

Ampullary cancer is a relatively rare gastrointestinal malignancy. The purpose of this study was to evaluate prognostic factors for survival and assess the benefits of adjuvant therapy following pancreaticoduodenectomy for this entity. Medline and EMBASE databases were searched to identify eligible studies from January 2000 to August 2019. Review Manager 5.3 statistical software was used for meta-analysis. 71 studies met the inclusion criteria and were included in the analysis for a total of 8280 patients. The median (range) 5-year overall survival and disease-free survival rates were 58% (32-82%) and 51% (28-73%) respectively. In meta-analysis, age >65 years at diagnosis, tumor size >20 mm, poor differentiation, pancreaticobiliary histotype, pT3-4 stage disease, presence of metastatic lymph node, number of metastatic nodes, perineural invasion, lymphovascular invasion, vascular invasion, pancreatic invasion, and positive surgical margins were independently associated with worse overall survival, whereas adjuvant therapy was associated with improved overall survival. In summary, in patients with ampullary cancer undergoing pancreaticoduodenectomy, tumor factors are the main predictors of worse survival and adjuvant treatment confers a survival benefit.

Endoscopic ampullectomy for non-invasive ampullary lesions: a single-center 10-year retrospective cohort study

BACKGROUND

Lesions involving the ampulla of Vater have traditionally been managed by surgical resection, albeit with high rates of morbidity and mortality. Endoscopic ampullectomy is increasingly recognized as an efficacious and safer treatment option. This study aims to evaluate the safety and efficacy of endoscopic ampullectomy for non-invasive ampullary lesions in a single tertiary referral center.

METHODS

Patients with non-invasive ampullary lesions, with or without familial adenomatous polyposis (FAP), were identified using pathology and endoscopy databases. The study included all patients who underwent the index ampullectomy between January 2007 and January 2017. Outcome parameters included accuracy of forceps biopsies, adverse events, success of endoscopic resection, and rate of recurrence.

RESULTS

A total of 53 patients underwent endoscopic ampullectomy over the 10-year period. Histological upstaging was seen in 37.8% of cases at ampullectomy compared to biopsy, including 5 cases (9.4%) of invasive adenocarcinoma. Adverse events occurred in 10 patients (18.9%) consisting of bleeding (11.3%), benign papillary stenosis (3.8%), acute pancreatitis (1.9%), and duodenal perforation (1.9%). Recurrence occurred in 32.7% over a median follow-up of 30 months (range 6-104 months), with the majority (18.4%) occurring at the first surveillance endoscopy. Nonetheless, 75% of recurrences were able to be cleared endoscopically. Endoscopic resection was successful in 91.1% of patients.

CONCLUSIONS

Endoscopic ampullectomy is an effective and safer therapeutic modality for non-invasive ampullary lesions, in addition to being a valuable diagnostic and staging tool. Nevertheless, careful patient selection and a commitment to endoscopic follow-up are of primary importance to achieve an optimal therapeutic outcome.

Prognostic Factors and the Role of Adjuvant Treatment in Periampullary Carcinoma: a Single-Centre Experience of 95 Patients

PURPOSE

The effect of adjuvant treatment on those undergoing pancreaticoduodenectomy (PD) for periampullary carcinomas (PAC) is not well studied. Most studies employed chemoradiation as the adjuvant modality. We aimed to analyse clinicopathological differences between types of PACs, the prognostic factors and the role of adjuvant therapy (chemotherapy in the majority).

METHODS

Patients with PAC who underwent PD from Jan 2011 to Dec 2015 were retrospectively analysed.

RESULTS

Ninety-five patients with PAC underwent PD in the study period. Ampullary carcinoma (AC) was the most common. Pancreatic carcinomas (PC) were larger. AC had lower T stage, perineural invasion (PNI) and R1 resections. Median overall survival (OS) was 32.7 months. On multivariate analysis, lymph node ratio (LNR) ≥ 0.2 and advanced T stage adversely affected the OS. Fifty-seven (66.3%) patients received adjuvant treatment, of which 50 had chemotherapy alone. Adjuvant treatment resulted in better OS in patients with T stage ≥ 3, lymph node involvement, LNR ≥ 0.2, lymphovascular invasion, PNI, tumour size > 2 cm, higher grade and distal cholangiocarcinoma.

CONCLUSION

In patients of PAC undergoing PD, AC had favourable clinicopathological profile. LNR ≥ 0.2 and advanced T stage adversely affected OS. Adjuvant treatment resulted in significantly better OS in patients with high-risk features.

Diagnosis and Treatment of Synchronous Lymphoma and Digestive System Carcinoma: Report of Four Cases and Literature Review

Objective: To investigate the diagnosis and treatment of synchronous lymphoma and digestive system carcinoma and review literature.

Materials and Methods: We retrospectively analyzed the clinical data of four cases of synchronous lymphoma and digestive system carcinoma treated at our hospital. The clinical manifestations, pathological results, and treatment strategies were investigated.

Results: One of the four cases was diagnosed as follicular lymphoma with gastric adenocarcinoma, and the other three were diagnosed as diffuse large B-cell lymphoma with digestive system adenocarcinoma in the liver, sigmoid colon, and duodenum papilla, respectively. The second carcinoma was initially discovered incidentally because of the stage examination of lymphoma or the patient's poor response to treatment. The diagnosis of synchronous lymphoma and digestive system carcinoma depended mainly on the pathological examination.

Conclusions: The accurate diagnosis of synchronous malignancies is challenging because they rarely occur. We suggest a scrupulous re-biopsy of extranodal lesions in patients with lymphoma to improve the diagnostic accuracy of related double primary tumors. Age, performance status, symptoms, pathological types, and tumor staging should be considered when formulating a treatment strategy. The systemic treatment regimens should include drugs targeting the synchronous tumors in question, and these remain to be explored further.

Diagnosis, risk stratification, and management of ampullary dysplasia by DNA flow cytometric analysis of paraffin-embedded tissue

The limited accuracy of endoscopic biopsy in detecting high-grade dysplasia or adenocarcinoma within ampullary adenoma or dysplasia has been reported. The natural history of ampullary dysplasia is also unclear, and there are no established guidelines to determine which patients with ampullary dysplasia require resection versus surveillance endoscopy. DNA flow cytometry was performed on 47 ampullary biopsies with low-grade dysplasia, 18 high-grade dysplasia, and 23 negative for dysplasia, as well as 11 cases of ampullary adenocarcinoma. Abnormal DNA content (aneuploidy or elevated 4N fraction > 6%) was identified in 9 (82%) of adenocarcinoma, 13 (72%) of high-grade dysplasia, 7 (15%) of low-grade dysplasia, and none (0%) of non-dysplastic mucosa. One-, 2-, and 7-year detection rates of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with abnormal DNA content were 57%, 86%, and 88%, respectively, whereas low-grade dysplasia patients in the setting of normal DNA content had 1-, 2-, and 7-year detection rates of 10%, 10%, and 10%, respectively. The univariate and multivariate hazard ratios (HRs) for subsequent detection of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 16.8 (p = <0.01) and 9.8 (p = <0.01), respectively. Among the 13 high-grade dysplasia patients with DNA content abnormality, 5 patients (38%) were subsequently found to have adenocarcinoma within a mean follow-up time of 3 months, whereas only 1 (20%) of the remaining 5 patients in the setting of normal DNA content developed adenocarcinoma in a month (HR = 2.6, p = 0.39). The overall 1- and 2-year detection rates of adenocarcinoma in all high-grade dysplasia patients (regardless of flow cytometric results) were 34% (95% confidence interval = 16-63%) and 47% (95% confidence interval = 23-79%), respectively. In conclusion, the majority of low-grade dysplasia patients (86%) in the setting of abnormal DNA content developed high-grade dysplasia or adenocarcinoma within 2 years and thus may benefit from resection, whereas those with normal DNA content may be followed with surveillance endoscopy. The presence of DNA content abnormality can also confirm a morphologic suspicion of high-grade dysplasia, which should be managed with resection, as nearly 50% of the high-grade dysplasia patients were found to have adenocarcinoma within 2 years.

New experience of endoscopic papillectomy for ampullary neoplasms

AIM

To establish the clinical value of endoscopic papillectomy for duodenal papillary tumor based on endoscopic and clinical characteristics.

PATIENTS AND METHODS

This single-center, retrospective study included 110 patients with duodenal papillary tumor who underwent endoscopic papillectomy between January 2006 and April 2017 at the gastrointestinal endoscopic center of the Chinese PLA General Hospital. Clinical data, postoperative pathology, procedure-related complications, and therapeutic outcomes were analyzed.

RESULTS

Endoscopic papillectomy was technically feasible in all patients, and was mainly performed by four experienced endoscopists. The primary success rate of endoscopic papillectomy for ampullary neoplasms was 78.2%. A total of 13 patients experienced recurrence during a mean follow-up period of 16.28 months (range 6-132 months), the predictive factors that were related to recurrence were complete resection (53.8% vs. 94.2%; P = 0.001), and final pathology findings (P = 0.001). Delayed hemorrhage, the most common procedure-related complication, occurred in 20% (22/110) of patients and was significantly related to intraoperative bleeding (P = 0.042). Pancreatitis was the second most common complication, which was closely related to intraoperative bleeding requiring intervention (P = 0.040) and larger tumor size (P = 0.044). Histology, type of resection, stent placement, sphincterotomy, and duration of procedure were not related to post-procedure hemorrhage or pancreatitis. Older age (63.7 ± 13.5 vs. 57.4 ± 12.2; P = 0.033), jaundice (47.8% vs. 13.8%; P = 0.001), endoscopic forceps biopsy diagnosis of high-grade intraepithelial neoplasia (82.6% vs. 14.9%; P = 0.001), tumor size ≥ 2 cm (60.9% vs. 34.5%; P = 0.022), and dilation of the bile duct (34.8% vs. 9.2%; P = 0.006) were clinical features for ampullary carcinoma. The rate of complete resection (52.2% vs. 92.0%; P = 0.001) and recurrence (34.8% vs. 6.8%; P = 0.001) were also related to the diagnosis of ampullary carcinoma at final pathology.

CONCLUSIONS

Endoscopic papillectomy is a feasible and reasonable option for both diagnosis and treatment of tumors of the duodenal papilla in properly selected patients.

Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study

Background

Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions.

Methods

All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence.

Results

We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733).

Conclusion

Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.

Pylorus-preserving pancreaticoduodenectomy versus standard pancreaticoduodenectomy in the treatment of duodenal papilla carcinoma

It is not known whether pylorus-preserving pancreaticoduodenectomy (PPPD) is as effective as the standard pancreaticoduodenectomy (SPD) in the treatment of duodenal papilla carcinoma (DPC). A retrospective cohort trial was undertaken to compare the results of these two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients who had undergone surgery for primary DPC between January 2003 and February 2010 were analyzed. According to the inclusion criteria and the surgical methods, 116 patients were divided into the PPPD group (n=43) and the SPD group (n=73). There were no significant differences in various indices, including surgery duration, extent of intraoperative hemorrhage and postoperative pathological indexes. The incidence of postoperative complications, including pancreatic fistula and delayed gastric emptying, were also similar between the two groups (20.9 vs. 21.9%; P=0.900 and 11.6 vs. 5.4%; P=0.402). Long-term survival and quality of life were identical following a median follow-up of 45.6 months (range, 4-144 months). Within 6 months, there was a decreased loss of appetite following the pylorus-preserving procedure (26.9 vs. 49.3; P=0.003). The procedures were equally effective for the treatment of DPC. PPPD offers minor advantages in the early postoperative period but not in the long term.

Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM

To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD).

METHODS

This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the χ² test and Fisher’s exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test.

RESULTS

In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (χ² = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047).

CONCLUSION

For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Radiofrequency ablation for intraductal extension of ampullary neoplasms

BACKGROUND AND AIMS

Extension of ampullary adenomas into the common bile duct (CBD) or pancreatic duct (PD) may be difficult to treat endoscopically. We evaluated the feasibility, safety, and efficacy of endoscopic radiofrequency ablation (RFA) in the management of ampullary neoplasms with intraductal extension.

METHODS

This was a multicenter, retrospective analysis of all patients with intraductal extension of ampullary neoplasms treated with endoscopic RFA between February 2012 and June 2015. Treatment success was defined as the absence of detectable intraductal polyps by ductography, visual inspection, and biopsy sampling.

RESULTS

Fourteen patients with adenoma extension into the CBD (13 ± 7 mm, n = 14) and PD (7 ± 2 mm, n = 3) underwent a median of 1 RFA sessions (range, 1-5). Additional modalities (thermal probes, argon plasma coagulation, and/or photodynamic therapy) were also used in 7 patients, and prophylactic stents were routinely placed. Thirteen assessable patients underwent a median of 2 surveillance ERCPs after completion of treatment over a median follow-up of 16 months (range, 5-46), with intraductal biopsy specimens showing no neoplasm in 12 patients at the conclusion of endoscopic treatment. Treatment success was achieved in 92%, including 100% of those treated with RFA alone. Adverse events occurred in 43% and included ductal strictures (5 patients) and retroduodenal abscess (1 patient), all of which were successfully treated endoscopically.

CONCLUSIONS

Endoscopic RFA, alone or in combination with other modalities, may effectively treat intraductal extension of ampullary neoplasms. Ductal strictures were common after RFA but responded to endoscopic stent therapy. RFA may be appropriate in selected patients, particularly when the main treatment alternative is pancreaticoduodenectomy.

Prognostic Factors and Survival of Patients with Carcinoma of the Ampulla of Vater after Pancreaticoduodenectomy

Background: Although carcinoma of the ampulla of Vater (CAV) is a rare tumor, accounting for just 0.2% of gastrointestinal cancers, the survival of CAV patients is unfavorable. The five-year rates have ranged from 36.8-75.2% in previous reports but there is a lack of data relating to Thai people. Also prognostic factors are controversial. Objectives: This study aimed to determine survival outcomes and to identify prognostic factors for a positive outcome for CAV patients after surgery. Methods: In this retrospective cohort study, data were collected from CAV patients who underwent surgery in Chiang Mai University Hospital from 2005 to 2012 for time to event analysis, the log rank test and univariate and multivariate Cox’s regression analysis. Results: There were 72 CAV patients recruited, 45.8% being male. The mean age was 65.1 ± 10.5 years and the median waiting time for surgery was 56.5 days (24.5-91.5). The 30 day mortality rate was 5.6%., while 5-yr survival was 33.3%. The average disease free survival was 14.6 months. Prognostic factors relating to recurrence were positive lymph nodes (50% VS 19.6% p = 0.015) and advanced stage (44.1% VS 18.4% p = 0.023). Multivariate analysis showed that the potential prognostic factors for CAV patients included recurrence, moderate and poor differentiation, comorbidities and a tumor size > 2.0 cm. Conclusions: The findings of the study indicate that the overall survival of CAV patients after surgery is quite fair, with a tendency for better outcome with early as compared to advanced lesions. The key prognostic factors were recurrence, moderate and poor differentiation, comorbidity and tumor size > 2.0 cm.

Indications and results of pancreatic stump duct occlusion after duodenopancreatectomy

Severe post-operative complications after pancreaticoduodenectomy (PD) are largely due to pancreatic fistula onset. The occlusion of the main pancreatic duct using synthetic glue may prevent these complications. Aim of this study is to describe this technique and to report short- and long-term results as well as the post-operative endocrine and exocrine insufficiency. Two hundred and four patients who underwent PD with occlusion of the main pancreatic duct in a period of 15 years were retrospectively analyzed. Post-operative complications and their management were the main aim of the study with particular focus on pancreatic fistula incidence and its treatment. At 1-year follow-up endocrine and exocrine functions were analyzed. We observed a 54 % pancreatic fistula incidence, most of which (77/204 patients) were a grade A fistula with little change in medical management. Twenty-eight patients developed a grade B fistula while only 2 % of patients (5/204) developed a grade C fistula. Nine patients required re-operation, 5 of whom had a post-operative grade C fistula. Post-operative mortality was 3.4 %. At 1-year follow-up, 31 % of patients developed a post-operative diabetes while exocrine insufficiency was encountered in 88 % of patients. The occlusion of the main pancreatic duct after PD can be considered a relatively safe and easy-to-perform procedure. It should be reserved to selected patients, especially in case of soft pancreatic texture and small pancreatic duct and in elderly patients with comorbidities, in whom pancreatic fistula-related complications could be life threatening.

Endoscopic resection of advanced and laterally spreading duodenal papillary tumors

Historically, neoplasia of the duodenal papilla has been managed surgically, which may be associated with substantial morbidity and mortality. In the absence of invasive cancer, even lesions with extensive lateral duodenal wall involvement, or limited intraductal extension may be cured endoscopically with a superior safety profile. Endoscopic papillectomy is associated with greater risks of adverse events such as bleeding than resection elsewhere in the gastrointestinal tract. Additionally site-specific complications such as pancreatitis exist. A structured approach to lesion assessment, adherence to technical aspects of resection, endoscopic management of complications and post-resection surveillance is required. Advances have been made in all facets of endoscopic papillary resection since its introduction in the 1980s; extending the boundaries of endoscopic cure, optimizing outcomes and enhancing patient safety. These will be the focus of the present review.

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.

Perioperative Blood Transfusion and the Prognosis of Pancreatic Cancer Surgery: Systematic Review and Meta-analysis

BACKGROUND

Perioperative blood transfusion (PBT) is common in pancreatic surgery. Recent studies have suggested that PBT may be associated with worse long-term outcomes.

METHODS

A systematic review and meta-analysis of studies comparing long-term clinical outcomes of cancer patients undergoing curative-intent pancreatic surgery with regard to occurrence of PBT was performed.

RESULTS

A total of 23 studies (4339 patients) were included in the systematic review, and 19 studies (3646 patients) were included in the meta-analysis. Nearly half (45.8 %) of all patients were female (range 25-60 %), and median age ranged from 59 to 72 years. About half (46.5 %, range 19-72 %) of the patients were transfused. Most had pancreatic ductal adenocarcinoma (69.5 %), while others had ampullary carcinoma (15.0 %), cholangiocarcinoma (7.4 %), or exocrine tumors of pancreas (8.1 %). Most (91.1 %) underwent pancreaticoduodenectomy, while the remaining patients underwent a total or distal pancreatectomy. The 5-year overall survival for all patients ranged from 0 to 65 %. Thirteen and nine of 19 studies reported a detrimental effect of PBT on survival on univariable and multivariable analysis, respectively. Overall, PBT was associated with shorter overall survival (pooled odds ratio 2.43, 95 % confidence interval 1.90-3.10); this finding was reproduced in sensitivity analysis.

CONCLUSIONS

Patients receiving PBT had significantly lower 5-year survival after curative-intent pancreatic surgery. Further research should focus on implementing guidelines for and discerning factors associated with the poor outcomes after PBT.

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

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.

Cancer of the ampulla of vater: current evaluation and therapy

Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.

Predictors of long-term survival following resection for ampullary carcinoma: a large retrospective French multicentric study

OBJECTIVES

Ampullary carcinoma is a rare tumor. There are neither sufficient available data related to management after resection of the neoplasm of the ampulla of Vater, nor any international recommendations. The aim of this study was to identify factors associated with recurrence and survival after curative resection.

METHODS

A retrospective follow-up study was conducted including patients with ampullary carcinoma who underwent resection with curative intent in 12 French surgical centers between January 1990 and November 2011.

RESULTS

In this study, 319 patients underwent surgical resection for an ampullary neoplasm. Disease recurred in 120 patients (37.6%), and the 5- and 10-year disease-free survival rates were 48.9% and 40.4%, respectively. In multivariable Cox regression, preoperative bilirubin, T stage, pancreaticobiliary histology subtype, and lymph node involvement were each significantly associated with the risk of recurrence.

CONCLUSIONS

Ampullary carcinomas are a heterogeneous group that can be classified as intestinal and pancreaticobiliary subtypes. Our findings indicate that pancreaticobiliary differentiation, advanced stage, and lymph node involvement are predictors of both poor disease-free and poor overall survival. It is still unclear what adjuvant treatment after curative resection of ampullary carcinoma is optimal. It would be informative to evaluate adjuvant therapy according to histological subtype.

Factors predicting survival and pathological subtype in patients with ampullary adenocarcinoma

BACKGROUND

Carcinoma of the ampulla of Vater is uncommon. This study aimed to clarify predictors of survival for ampullary adenocarcinoma and to identify characteristics of its two major pathological subtypes.

METHODS

Medical records were reviewed for 86 patients who underwent curative resection for ampullary adenocarcinoma between 2000 and 2012 at 12 principal hospitals in Kagawa, Japan.

RESULTS

Resection was most common among 75-79-year-old patients. Actuarial 1-, 3-, and 5-year postoperative survival rates for ampullary adenocarcinoma were 90%, 72.3%, and 69.1%, respectively. Preoperative biliary drainage; serum CA19-9 and total bilirubin levels; pathological grade; perineural, vascular, pancreatic, and duodenal invasion; nodal metastasis; UICC-T stage; and pancreatobiliary subtype were predictors of poor survival. An elevated serum CA19-9 level; an elevated total bilirubin level; lymphatic, vascular, perineural, and pancreatic invasion; and advanced overall tumor stage were more common in patients with pancreatobiliary-type tumors than in patients with intestinal-type tumors. Additionally, pathologic subtype analysis showed that each subtype had distinct prognostic factors.

CONCLUSIONS

Preoperative elevated serum CA19-9 and total bilirubin levels are prognostic factors for ampullary adenocarcinoma, and are both associated with pancreatobiliary-type tumors. Surgeons should be aware of these factors because pancreatobiliary-type adenocarcinoma is aggressively invasive and is associated with poor survival.

Prognostic factors for long-term survival in patients with ampullary carcinoma: the results of a 15-year observation period after pancreaticoduodenectomy

Introduction. Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15-year observation period. Methods. From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%) and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). Results. The overall 1-, 5-, 10-, and 15-year survival rates were 79%, 40%, 24%, and 10%, respectively. Within a mean observation period of 30 (0–205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement (P = 0.001), lymphatic vessel invasion (P = 0.0001), intraoperative administration of packed red blood cells (P = 0.03), an elevated CA 19-9 (P = 0.03), jaundice (P = 0.04), and an impaired patient condition (P = 0.01) are strong negative predictors for a reduced patient survival. Conclusions. Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic adenocarcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with this risk constellation.

Prognostic relevance of number and ratio of metastatic lymph nodes in resected carcinoma of the ampulla of Vater

OBJECTIVES

To explore the prognostic relevance of the number and ratio of metastatic lymph nodes in resected Carcinoma of the ampulla of Vater (CAV).

METHODS

The clinical data of 155 patients who underwent pancreaticoduodenectomy (PD) for cancer of the ampulla of Vater between January 1990 and December 2010 were retrospectively analyzed. Kaplan-Meier method was used in survival analysis and Log rank method in comparison. Multivariate analysis was performed using Cox proportional hazards model.

RESULTS

Among these 155 patients, the in-hospital mortality rate was 4.5%, lymph node positive disease was 21.3%, and the 5-year survival rate was 51.6%. Patients with a lymph node ratio (LNR) >20% were more likely to have tumor differentiation, depth of duodenal involvement, depth of pancreatic invasion, T-stage and TNM-Stage. The number of the metastatic lymph nodes is important prognostic factors of the CAV. Univariate analysis showed that the factors associated with the prognosis included tumor size (P=0.036), tumor differentiation (P=0.019), LNR (P=0.032), number of metastatic lymph nodes (P=0.024), lymph node metastasis (P=0.03), depth of pancreatic invasion (P=0.001), T-stage (P=0.002), TNM stage (P=0.001), elevated CA 19-9 (P=0.000), and jaundice (P=0.021). Multivariate analysis showed that the factors associated with the prognosis were the number of metastatic lymph nodes (P=0.032; RR: 1.283; 95% CI: 1.022-1.611), tumor size (P=0.043; RR: 1.736; 95% CI: 1.017-2.963), and elevated CA 19-9 (P=0.003; RR: 3.247; 95% CI: 1.504-7.010).

CONCLUSIONS

LNR is a useful factor for predicting the prognosis of the radical treatment for CAV, whereas the number of metastatic lymph nodes is the most important factor. Further research on the locations, number, and LNR will be clinically meaningful to improve survival in patients with CAV.

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.

Endoscopic approach to the patient with benign or malignant ampullary lesions

Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.

Resection margin involvement and tumour origin in pancreatic head cancer

BACKGROUND

Assessment of the origin of adenocarcinoma in pancreatoduodenectomy specimens (pancreatic, ampullary or biliary) and resection margin status is not performed in a consistent manner in different centres. The aim of this review was to identify the impact of such variations on patient outcome.

METHODS

A systematic literature search for articles on pancreatic, ampullary, distal bile duct and periampullary cancer was performed, with special attention to data on resection margin status, pathological examination and outcome.

RESULTS

The frequent reclassification of tumour origin following slide review, and the wide variation in published incidence of pancreatic (33-89 per cent), ampullary (5-42 per cent) and distal bile duct (5-38 per cent) cancers indicate that the histopathological distinction between the three cancer groups is less accurate than generally believed. Recent studies have shown that the wide range of rates of microscopic margin involvement (R1) in pancreatoduodenectomy specimens (18-85, 0-27 and 0-72 per cent respectively for pancreatic, ampullary and distal bile duct cancers) is mainly caused by differences in pathological assessment rather than surgical practice and patient selection. As a consequence of the existing inconsistency in reporting of these data items, the clinical significance of microscopic margin involvement in each of the three cancer groups remains unclear.

CONCLUSION

Inaccurate and inconsistent distinction between pancreatic, ampullary and distal bile duct cancer, combined with inaccuracies in resection margin assessment, results in obfuscation of key clinicopathological data. Specimen dissection technique plays a key role in the quality of the assessment of both tumour origin and margin status. Unless the pathological examination is meticulous and standardized, comparison of results between centres and observations in multicentre trials will remain of limited value.

Tumors of ampulla of Vater: A case series and review of chemotherapy options

Carcinomas of the Ampulla of Vater are rare tumors, accounting for 0.2% of gastrointestinal cancers. Compared with other biliary tract neoplasms, these tumors have a relatively favorable prognosis after surgical resection. Based on their epithelium of origin, two subtypes of ampullary carcinoma have been recently distinguished: intestinal and pancreatobiliary. This study evaluates histopathological features and outcomes of ampullary carcinoma and to compares the survival of these tumors to that of other biliary tract tumors. The chemotherapic options available for ampullary cancer are also reviewed. We analyzed data from 20 consecutive patients with ampullary carcinomas and 26 patients with other biliary tract carcinomas, observed in our Institution. Statistical analysis was performed by using either Fisher’s exact test or χ² test for categorical variables. Median time of survival was calculated and compared using the Log-Rank test. Similar distribution of demographic characteristics and stage between ampullary and other biliary tract cancers was observed. Patients with ampullary cancer underwent surgery more frequently than other biliary cancers while chemotherapy and radiotherapy were used equally. In accordance with the literature, a longer median survival was observed in the group of ampullary carcinomas.

Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy

PURPOSE

Postpancreatectomy hemorrhage (PPH) is one of the most serious complications after pancreatoduodenectomy (PD). This study analyzed and validated the International Study Group of Pancreatic Surgery (ISGPS) definition of PPH and aimed to identify risk factors for early (<24 h) and late PPH.

METHODS

Patients who underwent PD for pancreatic head tumors between 2001 and 2008 were included and complications were prospectively recorded. Factors associated with PPH were assessed by uni- and multivariate analysis.

RESULTS

Complete datasets were available for 796 patients. Classic and pylorus-preserving PD was performed in 13.8% and 86.2% of the patients, respectively. According to the ISGPS definition, PPH occurred in 29.1% of the cases (232 of 796 patients): 4.8% grade A, 15.2% grade B, and 9.2% grade C. The definition is based largely on surrogate markers (e.g., transfusion requirement) that are affected by other critical illnesses and more than 97% of patients with mild PPH had no clinical signs of bleeding. The need for postoperative intensive care as well as the incidence of pancreatic fistula, relaparotomy, and mortality rates significantly increased from grades A to C. Thirty-seven patients (4.6%) required interventional (endoscopy or angiography) and/or relaparotomy for PPH. Relaparotomy for PPH was performed in 3.1% of all patients. Independent risk factors for early PPH were preoperative anemia (hemoglobin, <11 mg/dl) and multivisceral resection while advanced age, chronic renal insufficiency, increased blood loss, and long operation time were associated with late PPH.

CONCLUSIONS

The ISGPS definition of PPH is feasible and applicable but produces a high rate of false positive mild PPH cases. The different grades still significantly correlate with relevant outcome variables, thus the definition discriminates postoperative courses, but a minor modification of the definition of mild PPH is suggested. The new results further demonstrate the need to optimize preoperative anemia and chronic renal insufficiency.

Endoscopic ultrasound for non-gastroenterologists: what you need to know

Endoscopic ultrasound (EUS) combines the use of flexible fiberoptic endoscopes with high-resolution ultrasound technology. It is increasingly used for the evaluation, staging, and diagnosis of many luminal and extraluminal gastrointestinal (GI) cancers, as well as non-GI tract ailments, including the staging of lung cancer. In the past decade, EUS has become available on a wide scale, with an increasing number of indications. The technology has been shown to be comparable with and often more sensitive than computed tomography scan and magnetic resonance imaging in staging many malignancies. The use of fine-needle aspiration and ultrasound-guided injection also allows for accurate tissue diagnosis and therapy of GI ailments. Despite increasing availability and indications for EUS over the past decade, general internists may not be aware of EUS technology, when to order an EUS, and how to integrate the results of an EUS into their management decisions. This article will review the general indications for EUS referral, limitations, and role of EUS in the practice of general medicine.

Differential features of pancreatobiliary- and intestinal-type ampullary carcinomas at MR imaging

PURPOSE

To define the differential imaging features of pancreatobiliary- and intestinal-type ampullary carcinomas at magnetic resonance (MR) imaging and to correlate these features with pathologic findings.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board; informed consent was waived. Fifty patients with surgically confirmed ampullary carcinoma and preoperative MR results were included. Two radiologists, blinded to histologic type of cancer, evaluated imaging findings in consensus. Univariate and multiple logistic regression analysis were performed to define imaging findings that were useful for differentiation of the two types of carcinomas.

RESULTS

On the basis of hematoxylin-eosin and immunohistochemical staining, 35 patients were classified as having pancreatobiliary type; and 15 patients, intestinal type. At MR, all of 15 intestinal carcinomas were nodular, whereas 16 (46%) of 35 pancreatobiliary carcinomas were infiltrative. Intestinal carcinomas were isointense (13 [87%] of 15) to hyperintense (two [13%] of 15), whereas 34% (12 of 35) of pancreatobiliary carcinomas manifested as hypointense compared with the duodenum on T2-weighted MR images (P = .034). Intestinal carcinoma commonly manifested with an oval filling defect at the distal end of the bile duct on MR cholangiopancreatographic (MRCP) images (11 [73%] of 15 vs four [11%] of 35 in pancreatobiliary type) (P < .001). At endoscopy, intestinal carcinoma manifested with an extramural protruding mass (n = 15, 100%) with a papillary surface (n = 11, 73%), whereas pancreatobiliary carcinoma manifested with intramural protruding (n = 5, 28%) or ulcerating (n = 1, 6%) gross morphologic features (P = .047) with a nonpapillary surface (n = 17, 94%) (P < .001). Multiple logistic regression analysis showed that an oval filling defect at the distal end of the bile duct was the only independent finding for differentiating intestinal from pancreatobiliary carcinoma (P = .027).

CONCLUSION

An oval filling defect at the distal end of the bile duct on MRCP images and an extramural protruding appearance with a papillary surface at endoscopy are likely to suggest intestinal ampullary carcinoma.

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.

Important Prognostic Factors in Adenocarcinoma of the Ampulla of Vater

Ampullary adenocarcinoma (AmpCA) carries a better overall survival (OS) rate than other periampullary cancers. We examined clinicopathologic features in AmpCA for impact on OS. Records of patients undergoing pancreaticoduodenectomy from 2000 to 2007 for AmpCA were reviewed and histological specimens were reanalyzed. Of 302 patients undergoing pancreaticoduodenectomy for malignancy, 45 (14.9%) had AmpCA. Mean age was 61.3 ± 12.2 years, mean tumor size was 2.6 ± 1.3 cm, 57 per cent were ≥ T3 tumors, 42 per cent were N1 stage, 13 (49%) had perineural invasion (PNI), and 29 (64%) had lymphovascular invasion (LVI). Thirteen were intestinal (29%), 14 were pancreaticobiliary (31%), and 18 were mixed (40%). Median OS was 42 months (range 4-80 mos). On log rank testing, ≥ T3 (24 vs 65 mos, P < 0.01), N1 (25 vs 61 mos, P < 0.01), poor differentiation (24 vs 44 mos, P = 0.01), pancreaticobiliary subtype (23 vs 44 mos, P = 0.01), and PNI (23 vs 44 mos, P < 0.01) were significant for worse survival. By multivariate analysis, N1 disease (hazard ratio [HR] 4.50,95% confidence interval [CI] 1.16-17.40) and PNI (HR 4.62, CI 1.11-19.21) maintained associations with worse survival, whereas histological subtype did not. N1 disease and presence of PNI demonstrated independent associations with worse survival. Given high percentage of mixed histology, PNI may be more informative than the subtype in predicting outcome for patients with AmpCA.

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.

Signet-ring cell carcinoma of ampulla of Vater: Contrast-enhanced ultrasound findings

Signet-ring cell carcinoma (SRCC) of ampulla of Vater is extremely uncommon, and less than 15 cases have been reported so far in literature. It mainly occurs in elderly people (median age 57 years). We report a rare case of SRCC of the ampulla of Vater in a 38-year-old woman who presented with a small tumor at the Vater, discovered by the contrast-enhanced ultrasound (CEUS). Histopathological examination showed prominent signet-ring features. We also describe the imaging features of SRCC of ampulla of Vater in CEUS.