Prognostic Factors for Long-Term Survival in Patients with Ampullary Carcinoma: The Results of a 15-Year Observation Period after Pancreaticoduodenectomy

Abstract

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.

Can isolated pancreaticojejunostomy reduce pancreas fistula after pancreaticoduodenectomy with Roux-en-Y reconstruction?

“…The predictive factors for pancreatic leakage and fistula development can be listed as a small sized duct, consistency of the pancreatic tissue, requirement for extended resections, drain localization, quantity of intraoperative blood loss and obesity (14,16). Perhaps, the most significant ones among these are pancreatic anatomy and operative techniques (11,17).…”

Whipple procedure: patient selection and special considerations

“…A few studies demonstrate that administration of packed red blood cells, increased tumor stage, substantial invasion depth of the tumor, histological grading, positive resection border, vascular and lymphatic vessel invasion, and Ca199 levels higher than 37 U/L were each associated with a significantly reduced longterm survival. 65 There is currently no significant difference in overall survival between patients who undergo a pyloruspreserving PD or a classic Whipple with a standard lymphadenectomy. Owing to the location of these lesions, the patients present with symptoms earlier at the time of diagnosis, and these lesions have a high rate of being suc cessfully resected.…”

“…There are two histological types: intestinal and pancreatobiliary. 65 The intestinal type has a better prognosis. A few studies demonstrate that administration of packed red blood cells, increased tumor stage, substantial invasion depth of the tumor, histological grading, positive resection border, vascular and lymphatic vessel invasion, and Ca199 levels higher than 37 U/L were each associated with a significantly reduced longterm survival.…”

“…If the resec tion margin contains microscopic evidence of cancer of lymphatic invasion, the patient should be offered chemo and radiation therapies. Unfortunately, the biopsynegative rate is 40%-85%, 65 as the lesion may appear benign. 65 If this is the case, endoscopic resection may be offered first, followed by evaluation of the larger specimen with the submucosal tissue.…”

“…Unfortunately, the biopsynegative rate is 40%-85%, 65 as the lesion may appear benign. 65 If this is the case, endoscopic resection may be offered first, followed by evaluation of the larger specimen with the submucosal tissue. If there is a high suspicion of cancer, and the patient is a good operative candidate, an operation should be offered.…”