Transduodenal ampullectomy for ampullary neoplasms - a systematic review and meta-analysis

Abstract

Objective: To assess the role of transduodenal ampullectomy (TDA) in the treatment of ampullary neoplasms. Methods: Systematic review of Medline and PubMed to identify articles which reported TDAs for ampullary neoplasms. A meta-analysis to compare TDA and PD was performed by using Review Manager 5.3. Results: Twenty-three studies fulfilled the inclusion criteria and included 382 patients that underwent TDA. Mean age was 65.2 years and median tumour size 2.28 cm. Overall morbidity was 27.5% and mortality 0.26%. Diagnostic accuracy of preoperative biopsy varied from 40 to 90%. The accuracy of intraoperative frozen section was 89%. Ninety-three percent of the patients had microscopically free margins. Adenocarcinoma was present in 25% of the cases (Tis and T1 83%) and the overall recurrence rate was 18% (n = 69). Twenty-two patients underwent salvage PD (5.8%) following TDA and another 23 patients had PD due to disease recurrence. Eight patients with inadequate local excision were not fit for PD. Mean duration of follow-up was 41.2 months and overall survival 87%. TDA was significantly associated with lower morbidity (RR 0.532, 95% CI = 0.3060.925; p = 0.025), shorter operative time (SMD −2.363, 95% CI = −2.839–1.887; p < 0.001) and less intraoperative blood loss (SMD −1.24, 95% CI = −1.65–0.83; p < 0.001) when compared to PD. Conclusion: TDA is a safe and feasible treatment for early stage ampullary cancer. TDA may be suitable for elderly patients with higher surgical risk. Intraoperative frozen section and periduodenal lymph node sampling are imperative.Tabled 1AuthorsPatientGender M,FMean AgeASA GradeMedian TumourFalse negativeDiagnosticFrozen SectionAdenomaAdenomaAdenocarcinomaMorbidity (%)Morbidity (%)Mean HospitalDisease RecuResection MarOverallAdditional PDBlood LossOperative tinLow GradeHigh GradeT(S)T1T2R0R1Beger et al, 199918––––16%74%–8080100–0–612661.5720––Posner et al, 200121–61–2333%–-181921048014221038851––Nikfarjam et al, 200153,275III80%, II20%2.5–––0042001011800No transfusion180Bohra et al, 20021512,367–2.566%41%–02221813013414131650––Marina et al, 200484,468-–12.50%87.5100%2––150250–212328.587.52––Dixon et al, 20051910,964–2.7––75%1192061370-5291451003230ml–Menegh etti et al, 200530–66––17%66%85%23––051–0–51068–4––Genc et al, 200710,167II2100%0%0%00001000–110151000––Shiba et al, 201010,130I5100%0%0%0001000–020101000––Honda et al, 201021,158II–0%100%–000020001302011000102ml208Hoyela et al, 201021,166–2.550%50%50%101010–0–22027502––Onkendi et al, 20149–––––––N/A––––––0–3––52–0––Kim et al, 201126–58–––47.60%65%14152202409125118–5––Lee et al, 2016189,959II 11%, II 67%1.6–––00012603301021625094.56175ml233Gao et al, 20162213,968–1.2–74%90%000418013.6014.57220757734135ml175Mathur et al, 201432–64––6.2581.5100%30––020–0–42932816––Ahn et al, 201021,165I2.250%100%–11–000008.502011050ml255Schneider et al, 20154416,2867––6.80%93%97,7%40373120372.210144054981––Ceppa et al, 20134116,2557––6%90%–23–––5042010.1–3741–0––Rattner et al, 199614––––33%67%–9–––5014010.511––––4––Heidecke et al, 200212––––27.2–86%18612020400–7––45857––Demetriades et al, 200620–––1.310%–100%8––010210083––85750––Tien et al, 2009208,1265.2–1.6––90%17––0305013.42––24901–– Open table in a new tab