Pancreatoduodenectomy for Tumors of Vater’s Ampulla: Report on 94 Consecutive Patients

Abstract

Evaluation of prognostic factors of adenocarcinoma of Vater's ampulla is still a matter of debate. The aim of this study was to evaluate retrospectively factors that influence early and long-term outcomes in a 20-year single-institution experience on ampullary carcinoma. A total of 94 consecutive patients with ampullary carcinoma or adenoma with severe dysplasia were managed from 1981 to 2002. Among them, 64 underwent pancreatoduodenectomy, and the remaining 30 submitted to surgical (n = 5) or endoscopic (n = 25) palliative treatment. Demographic, clinical, and pathologic data were collected, and a comparison was made between patients who did or did not undergo resection. Standard statistical analyses were carried out in an attempt to establish a correlation between clinical variables, intraoperative and pathologic factors, and survival in patients with resection. A total of 85 (90.4%) patients had potentially resectable lesions due to the extent of the tumor, but only 64 (68%) underwent curative resection. The surgical morbidity rate was 34.3%. Postoperative mortality was 9.3%, with no deaths among the 38 more recently treated patients. Median survivals were 9 and 54 months for nonresected and resected patients, respectively. The overall 5-year survival was 64.4% for patients undergoing pancreatoduodenectomy. Survival was found to be significantly affected by resection, tumor size, tumor grade, and tumor infiltration. Patients with negative lymph nodes show a trend toward longer survival. In a multivariate analysis, only the depth of tumor infiltration influenced patient survival. Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma and adenomas with high-grade dysplasia, with a good chance of long-term survival. Surgical resection remains the most important factor influencing outcome.

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

“…Interestingly, a preoperative hemoglobin value of less than 11 g/dl was OR odds ratio, CI confidence interval, CRI chronic renal insufficiency also a risk factor for early PPH, which should be taken into account in the preoperative workup and optimization of the patient's clinical condition before PD. This is in line with recent findings where intraoperative red blood cell transfusions adversely influenced long-term survival in patients undergoing pancreatic resection for ampullary cancer [18,19]. Intraoperative transfusion during pancreatoduodenectomy was also identified as a significant risk factor for the need of postoperative extended ICU stay [20].…”

Prognostic Impact of Perineural Invasion Following Pancreatoduodenectomy With Lymphadenectomy for Ampullary Carcinoma

“…However, some patients eventually succumb to the disease, with 5-year survival rates following resection ranging from 38 to 67% [1,[3][4][5][6][7][8][9]. Many predictive factors have been reported to influence survival following ampullary carcinoma resection, including depth of tumor infiltration [5,7,9,10], lymph node metastasis [1,4,6,[9][10][11][12], TNM stage [5,8], pancreatic invasion [4,12], and perineural invasion [13,14]. Identification of predictors of failure and survival following potentially curative resection should enable selection of candidates for adjuvant treatment.…”

Expression of CD24, P-cadherin and S100A4 in tumors of the ampulla of Vater

“…6 Early detection but also biologic differences are held responsible for the better prognosis of ampullary tumors following pancreaticoduodenectomy compared with other periampullary tumors (median survival 30-50 months, 5-year survival rate 21-64%). [7][8][9][10][11][12][13] Histologically, several subtypes of ampullary carcinomas can be distinguished, obviously deriving from the different types of mucosa adjoining the Vaterian system. 1,14 According to the classification by the Armed Forces Institute of Pathology (AFIP) an intestinal type, resembling carcinomas of intestinal origin and a pancreatico-biliary type, resembling carcinomas of the extrahepatic bile ducts or the pancreas are the most common subtypes and account for 70-95% of cases.…”