Surgical Outcomes and Comparative Analysis of Transduodenal Ampullectomy and Pancreaticoduodenectomy: A Single-Center Study

Recurrent ascending cholangitis secondary to food reflux following transduodenal resection of an ampullary adenoma

Ampullary lesions, including adenomas and early-stage carcinomas, pose a diagnostic and therapeutic challenge because of their location and proximity to the pancreatic and bile ducts. Transduodenal ampullectomy offers a targeted approach for the resection of these lesions while preserving the integrity of the pancreaticobiliary system. Moreover, transduodenal ampullectomy is associated with favourable postoperative outcomes, including low rates of morbidity and mortality, as well as preservation of pancreatic and biliary function. However, potential complications such as ascending cholangitis pancreatic leakage, bleeding and duodenal stenosis can occur, which would impact the postoperative quality of life. Addressing these outcomes might require either endoscopic procedures or surgical interventions. We present an exceedingly uncommon case of recurrent ascending cholangitis resulting from reflux of food particles into the common bile duct that was treated successfully with a Roux-en-Y hepaticojejunostomy and gastroenterostomy.

Pushing the Boundaries of Ampullectomy for Benign Ampullary Tumors: 25-Year Outcomes of Surgical Ampullary Resection Associated with Duodenectomy or Biliary Resection

Background: Surgical resection for ampullary lesions lacks clear guidelines. Pancreaticoduodenectomy (PD) is the standard treatment for malignant ampullary tumors but is often excessive for ampullary adenomas (AAs) due to its high morbidity and mortality. Transduodenal ampullectomy (TDA) is generally reserved for small benign lesions where endoscopic treatment fails, but its role in early ampullary cancers is debatable. This study presents our 25-year outcomes with TDA for benign ampullary tumors. Methods: We conducted a retrospective cohort study with prospectively collected data from patients with benign ampullary lesions who underwent TDA between January 1996 and November 2023. Primary outcomes were the 30-day overall and severe (Clavien-Dindo ≥ IIIa) morbidity rates and the 90-day mortality rate. Categoric variables were presented as absolute and relative frequencies, and quantitative variables were presented as means (standard deviation, SD) or medians (range or interquartile range, IQR). Results: Fifty-three patients (29 male; mean [SD] age 62.5 [14.6] years) underwent TDA. The 30-day morbidity rate was 32.1% (17/53 patients), with five (9.4%) cases being severe. The 90-day mortality rate was 1.9%. Definitive histopathology identified 38 (71.7%) AAs and five (9.4%) infiltrating ampullary adenocarcinomas, two (40.0%) of which required subsequent PD. Six (11.3%) patients experienced recurrence. Overall, nine (16.9%) patients died. Conclusions: TDA is a safe and effective technique with acceptable morbidity for non-infiltrating lesions, especially in patients with poor clinical status. Choosing between TDA and PD depends on tumor size, dysplasia grade, and institutional expertise. Lifelong endoscopic surveillance post-TDA is essential for timely recurrence detection.

Transduodenal ampullectomy is an effective surgical exploration procedure for unexplained dilation of the cholangiopancreatic duct

BACKGROUND

The clinical diagnosis and treatment of dilation of the cholangiopancreatic duct in patients with ambiguous ampullary disease, termed unexplained dilation of the cholangiopancreatic duct (UDCD), is commonly difficult. This study aimed to evaluate the applicability of transduodenal ampullectomy (TDA) for the diagnosis and treatment of UDCD.

METHODS

We first proposed a surgical exploration procedure based on the TDA and applied it in a representative UDCD patient. We retrospectively analyzed the pathological diagnosis and prognosis of 14 patients at our hospital and 189 patients reported in existing studies who were treated with TDA between January 2010 and December 2022.

RESULTS

TDA can be used to radically explore the ampullary region and harvest adequate pathological tissue, which is helpful for identifying the cause of UDCD. The diagnostic rate of intraoperative frozen pathology was greater than that of preoperative endoscopic biopsy (78.41% vs. 65.94%, P = 0.044). The postoperative complication rate was 27.07%, with a mortality rate of 0.00%. The 5-year survival rate was 68.31% in patients with adenocarcinoma, 85.99% in patients with adenoma with HGD/pTis, and 100% in patients with benign lesions, and these had a statistically significant difference (P = 0.021).

CONCLUSIONS

TDA-based surgical exploration can be used as a safe and effective transitional procedure in the treatment of UDCD.

Prognostic efficacy of lymph node parameters in resected ampullary adenocarcinoma based on long-term follow-up data after adjuvant treatment

BACKGROUND

Lymph node (LN) metastasis is an important prognostic factor in the ampulla of Vater (AoV) adenocarcinoma. Various LN parameters have been proposed, but their prognostic efficacy has not been compared in the same population. We aimed to evaluate the prognostic values of LN parameters in AoV adenocarcinoma patients who underwent surgical resection and adjuvant treatment based on the long-term follow-up data.

METHODS

A total of 86 patients with surgically resected AoV adenocarcinoma followed by adjuvant treatment were analyzed. We evaluated the prognostic values of various LN parameters such as pathologic N stage, number of metastatic regional LN (LNN), LN ratio (LNR), and log odds of positive LNs (LODDS). Each LN parameter was separately analyzed using Cox regression models with the same confounders.

RESULTS

The median follow-up period was 69.4 months, and the median overall survival (OS) was 114 months. The median number of dissected LNs is 15, with an interquartile range of 8 to 25. In the univariable analyses, all LN parameters showed significant prognostic efficacy for OS, disease-free survival (DFS), and distant metastasis-free survival (DMFS). In the multivariable Cox regression analyses, LNN ≥ 2 was a statistically significant prognostic factor for OS (hazard ratio (HR) 2.10, 95% confidence interval (CI), 1.11-3.97; p = 0.022), DFS (HR 2.51, 95% CI 1.28-4.93; p = 0.007), and DMFS (HR 2.74, 95% CI 1.39-5.41; p = 0.004). LNR showed significant prognostic performance for DFS (HR 2.35, 95% CI 1.23-4.50; p = 0.010), and DMFS (HR 2.26, 95% CI 1.17-4.35; p = 0.015). N stage showed significant prognostic performance in DFS (HR 1.55 for pN1; p = 0.243 and HR 4.31 for pN2; p = 0.003), DMFS (HR 1.46 for pN1; p = 0.323 and 4.59 for pN2; p = 0.002). LODDS and the presence of LN metastasis, did not demonstrate significant prognostic value across survival outcomes.

CONCLUSIONS

LN parameters showed good long-term predictive performance in AoV adenocarcinoma patients treated with curative resection and adjuvant treatments. Among LN parameters, LNN ≥ 2 showed better prognostic value than others. Further large-scale studies are needed to validate the clinical usefulness of various LN parameters.

Predicting lymph node metastasis using preoperative parameters in patients with T1 ampulla of vater cancer

BACKGROUND

Lymph node (LN) metastasis is an established prognostic factor for patients with surgically resected ampulla of Vater (AoV) cancer. The standard procedure for radical resection, including removal of regional LNs, is pancreaticoduodenectomy (PD); however, local excision has been considered as an alternative option for patients in the early stage cancer with significant comorbidities. In the present study, we elucidated the preoperative factors associated with LN metastasis to determine the appropriate surgical extent for T1 AoV cancer.

METHODS

We included patients who underwent surgery for T1 AoV cancer at Samsung Medical Center and Severance Hospital between 2000 and 2019. Risk factors were analyzed to identify the preoperative parameters associated with LN metastasis or regional LN recurrence during follow-up. Finally, using the identified risk factors, a prediction model was constructed.

RESULTS

Among 342 patients, 311 patients underwent PD, whereas 31 patients underwent transduodenal ampullectomy. Fourty-eight patients had LN metastasis according to pathology report, and two patients presented with regional LN recurrence. Age, carbohydrate antigen 19 - 9 (CA 19 - 9), and tumor differentiation were identified as factors associated with the increased risk of LN metastasis or regional LN recurrence. The area under the curve of the prediction model with these three factors was 0.728.

CONCLUSION

Our newly developed prediction model using age, CA 19 - 9, and tumor differentiation can help select patients who require PD over local excision. Nevertheless, additional in-depth analysis is warranted to select appropriate surgical extent for patients with presumed T1 AoV cancer.

Endoscopic vacuum therapy (eVAC) combined with continuous perianastomotic irrigation for prevention of anastomotic leak after surgical ampullectomy

PURPOSE

Transduodenal surgical ampullectomy (tAMP) with papillary reimplantation is a valid alternative to pancreaticoduodenectomy for lesions of the periampullary region not amenable to endoscopic resection. As tAMP is burdened by high rates of biliopancreatic-enteric anastomotic leak, we tested preventive endoluminal vacuum therapy (eVAC) combined with post-operative continuous perianastomotic irrigation (CPI) to reduce such anastomotic leak.

METHODS

Between 10/2013 and 09/2023, 37 patients undergoing laparotomic tAMP (with or without jejunal transposition) and papillary reimplantation at Hirslanden Klinik Zurich were retrospectively analysed; of these, 16 received prophylactic eVAC combined with CPI, while the remaining represented the historical cohort.

RESULTS

The eVAC-CPI-group and the historical-cohort were homogeneous in demographic characteristics. Surgery in the prophylactic eVAC-CPI-group lasted about 30 min longer due to eVAC application (p = 0.008). The biliopancreatico-enteric anastomotic leak rates were 6.2% in the eVAC-CIP-group vs. 19.0% in the historical-cohort (p = 0.266). Along, a strong trend of less severe post-operative complications in general (p = 0.073), and borderline-significantly less cases of acute pancreatitis (p = 0.057) and tAMP-related re-operations or re-interventions (p = 0.057) in particular, were observed in the eVAC-CPI-group. The only anastomotic leak in the eVAC-CPI-group was successfully managed through repeated cycles of eVAC. The device was well tolerated by all patients; no vacuum/irrigation-related complications or malfunctioning occurred.

CONCLUSION

Our study is the first to provide some technical insights demonstrating the safety and feasibility of a prophylactic approach with eVAC and perianastomotic irrigation to reduce anastomotic leak after tAMP. Increasing the number of subjects will confirm the benefit of our promising results.

Early-Stage Ampullary Cancer: Is Local Excision an Effective Alternative to Radical Resection?

BACKGROUND

The efficacy of local excision (transduodenal or endoscopic ampullectomy) in treating early-stage ampullary cancer has not been well defined.

STUDY DESIGN

We queried the National Cancer Database to identify patients undergoing either local tumor excision or radical resection for early-stage (cTis-T2, N0, M0) ampullary adenocarcinoma between 2004 and 2018. Cox modeling was used to identify factors associated with overall survival. Patients undergoing local excision were then 1:1 propensity score-matched for demographics, hospital level, and histopathological factors to those undergoing radical resection. The Kaplan-Meier method was used to compare overall survival (OS) profiles for matched cohorts.

RESULTS

A total of 1,544 patients met inclusion criteria. A total of 218 (14%) underwent local tumor excision, and 1,326 (86%) radical resection. On propensity score matching, 218 patients undergoing local excision were successfully matched to 218 patients undergoing radical resection. On comparison of matched cohorts, those undergoing local excision had lower rate of margin-negative (R0) resection (85.1% vs 99%, p < 0.001) and lower median lymph node count (0 vs 13, p < 0.001) but had significantly shorter length of initial hospitalization (median days: 1 vs 10 days, p < 0.001), lower rate of 30-day readmission (3.3% vs 12.0%, p = 0.001), and lower rate of 30-day mortality (1.8% vs 6.5%, p = 0.016) than patients undergoing radical resection. There was no statistically significant difference in OS between the matched cohorts (46.9% vs 52.0%, p = 0.46).

CONCLUSIONS

In patients presenting with early-stage ampullary adenocarcinoma, local tumor excision is associated with higher rate of R1 resection but accelerated postprocedure recovery and patterns of OS comparable with those after radical resection.

SEOM-GEMCAD-TTD clinical guidelines for localized rectal cancer (2021)

The management of localized rectal cancer requires a multidisciplinary approach to optimize outcomes, reduce morbidity and prevent under or overtreatments. While early stages may obtain benefit of local resections without any additional therapies, locally advanced rectal cancer becomes a challenge defining the better sequential strategy of surgery, radiotherapy and chemotherapy. The latest results of international phase III studies have positioned the total neoadjuvant therapy as a potential new standard of care in high risk rectal cancers, however, the best schedule is still not well defined.