Periampullary Carcinoma Research Articles

Rare Case of Periampullary Duodenal Carcinoma

Periampullary carcinoma is a malignancy that appears around the vatteri ampulla. This malignancy can originate from the pancreas, duodenum, and distal choledochal duct. Duodenal cancer is a very rare case, only about 0.3% of the gastrointestinal malignancies. Reported cases are increasing with the increasing use of esophagogastroduodenoscopy. The most frequently found carcinomas of the duodenum include adenocarcinoma, carcinoid, lymphoma, and leiomyosarcoma. The symptoms of these carcinomas are often not specific so the diagnosis is often late, leading to a poor prognosis. Early diagnosis and proper therapy provide a good prognosis. The case reported here representeda 52-year-old woman presented with hematemesis melena, anemia, jaundice, epigastric mass, right hypochondrial pain, and weight loss. From the esophagogastroduodenoscopy, the mass was found to obstruct half of the duodenum lumen and bleeding, which was easily triggered, was observed in the second part of the duodenum. CT scan revealed a mass in the head of the pancreas with gall bladder hydrops and obstruction of the intra and extra-hepatic billier system. After a Whipple operation Laparotomy, the histology showed papillary adenocarcinoma duodenum. Patients then underwen chemotherapy with 5 fluorouracil regimen. Patient's clinical condition is currently improving and no complaint is conveyed by the patient.

Total laparoscopic pancreaticoduodenectomy in 26 patients: single surgeon experience

Background: Total laparoscopic pancreaticoduodenectomy (TLPD) has become more feasible and preferred surgery for periampullary tumour. With the innovation of latest equipment and continuous learning curve, this has become more sophisticated and rampant, along the advantages of minimal invasive surgery. Methods: We analysed data of all the 26 patients who underwent TLPD from October 2015 to November 2019. Preoperative haematological, liver function test, tumour marker, MRCP, triphasic CT, scan with pancreatic protocol, endoscopic ultrasound guided fine needle aspiration or brush cytology done for confirmation of diagnosis, nodal status and operability. Meticulously selected patients with periampullary carcinoma of tumour size≤2.5 cm included. Demographic data, operative time, length of hospital stay, post-operative complication and pathological analyses of resected specimen (en bloc) observed. Results: TLPD for periampullary tumours attempted in twenty-six patients among them six converted to open surgery. Patients were of both genders and mean age was 45 (27-60, SD7.4) years. The mean operative time was 353 SD 28.77 (306-420) minutes. Postoperatively, there were few complications and mean length of hospital stay was 11 (9-13 days) days. The histopathology revealed maximum no. of cholangiocarcinoma with negative margins and positive nodes in all the patients.Conclusions: TLPD is feasible, safe and promising alternative to the standard open surgery with expert hands. This has benefits of short hospital stay, less blood loss, cosmetic, early recovery with few complications. Short-term surgical outcomes are superior or comparable to open surgery.

Prognostic value of carcinoembryonic antigen and carbohydrate antigen 19–9 in periampullary cancer patients receiving pancreaticoduodenectomy

BackgroundWe assessed the use of serum concentrations of carbohydrate antigen (CA) 19–9 and carcinoembryonic antigen (CEA) measured during the preoperative diagnostic workup as prognostic factors for survival in patients with periampullary carcinoma. MethodsA retrospective review of patients diagnosed with periampullary carcinoma who underwent radical surgery was conducted. Factors related to the survival of periampullary carcinoma patients, including CA 19–9 and CEA, were analyzed. ResultsThe mean age of the 112 patients included in the results was 66.41 ± 10.513 years. In the study, the percentage of patients with elevated serum CA 19–9 and CEA concentrations was 65.2% and 24.1%, respectively. CA 19–9 concentrations were correlated with the tumor stage, pre-operative jaundice, and lymphovascular invasion, but CEA concentrations were not. The median overall survival was longer for the normal serum CA 19-9 group than the group with increased CA 19–9 (56 months vs. 25 months, p = 0.003); however, there was no statistically significant difference between the normal serum CEA group and the group with increased CEA (43 months vs. 25 months, p = 0.077). Independent factors related to overall survival were sex, age, stage, presence of jaundice, lymphovascular invasion, perineural invasion, margin status, and elevated serum CA 19–9 concentrations. ConclusionsPeriampullary carcinoma patients with elevated serum CA 19–9 concentrations at diagnosis are expected to have poor overall survival. CA 19–9 may be a useful marker for predicting prognosis in patients with periampullary carcinoma at the time of diagnosis.

Perioperative Outcome of Systematic Mesopancreas Dissection for Pancreatic and Periampullary Carcinoma at a Tertiary Referral Centre from a Low-middle Income Country

Purpose: Margin negative resection is considered as the surrogate marker of quality surgery. However, in pancreatic cancer the incidence of R1 resection is high despite of a very good quality surgery. Total mesopancreas excision has been considered to improve the margin negative resection and the lymph node yield. Amongst various techniques of mesopancreas excision (SMD), systematic mesopancreas dissection is applicable to pancreatic as well as other periampullary carcinoma. Objective: This study has been done to compare the perioperative outcomes, the lymph node yield and the margin status in patients who undergo standard pancreaticoduodenectomy (ST-PD) and SMD pancreaticoduodenectomy (SMD-PD) for pancreatic and periampullary carcinoma. Methods: A retrospective comparative study was conducted in patients who underwent pancreaticoduodenectomy for pancreatic and periampullary carcinoma in a single unit of Gastrointestinal and Hepatopancreatobiliary surgery at Tribhuvan University Teaching Hospital, Nepal. The demographics, indication of surgery, duration of surgery, intraoperative blood loss, incidence of procedure-specific complications as defined by International study group on pancreatic surgery (ISGPS), length of hospital stay, perioperative mortality, stage of the disease, lymph node yield and margin status were compared between the SMD-PD and ST-PD. Results: Total of 33 patients underwent SMD-PD with the mean age of 56.7 ± 12.9 years with 63.6% of patients being male. The most common indication of surgery was ampullary carcinoma. The demographic data was comparable with the historical data of 45 patients who underwent ST-PD. The duration of surgery (344.2±48.6 mins vs 374.2 ± 54.9 mins) and intraoperative blood loss (436.4 ± 171.3 ml vs 481.8 ± 196.4 ml) was found to be comparable with the patients who underwent SMD-PD. However, the incidence of postoperative pancreatic fistula and perioperative mortality were less in patients who underwent SMD-PD as compared to the patients who underwent ST-PD (21.2% vs 26.7% and 9.1% vs 11.1% respectively). The rate of margin negative resection was high (97% vs 91.1%). The median lymph node yield was significantly high in patients who underwent SMD-PD (15 vs 6, p < 0.05). Conclusion: SMD-PD is feasible and should be done not only for pancreatic carcinoma but also for other periampullary carcinoma.

Early experience of systematic mesopancreas dissection (SMD) for pancreatic and periampullary carcinoma

Introduction: The incidence of R1 resection is high in pancreatic cancer despite of a good quality surgery. Amongst various techniques of mesopancreas excision, SMD is applicable to pancreatic and other periampullary carcinoma. This study has been conducted to compare the perioperative outcomes, the lymph node yield and the margin status in patients who underwent standard pancreaticoduodenectomy and SMD pancreaticoduodenectomy for pancreatic and periampullary carcinoma.

Biliary Pressure Monitoring and its Clinical Correlation in Patients with Obstructive Jaundice

Introduction: Biliary pressure has been postulated to have a direct impact on cholangiovenous reflex and cholangitis in patients with obstructive jaundice .Only limited human studies are available regarding biliary pressure monitoring. Methods: A total of 30 patients with obstructive jaundice either benign or malignant and who didn't undergo any interventional or surgical procedure for relief of the jaundice were included in the study.The clinical and demographic details were noted and Liver function test was taken on the day of biliary decompression. Bile pressure was monitored intraoperatively with a pressure transducer system proximal to the obstruction. In patients who undergo PTBD ,bile pressure was noted immediately after inserting the Chiba needle. Results: A total of 30 patients were included in the study (19 males and 11 females). The mean age of the patients included were 55.9 years.The etiology of obstructive jaundice was periampullary carcinoma in 13 patients , carcinoma head of pancreas in 3 patients, carcinoma gallbladder in 3 patients , hilar cholangiocarcinoma in 6 patients ,postcholecystectomy biliary stricture in 1 patient ,Chronic pancreatitis with distal CBD compression in 2 patients, Post Liver transplant CBD stricture in 1 patient and choledocholithiasis with cholangitis in patient. (19 distal obstruction and 11 proximal obstruction).The mean biliary pressure in patients with distal obstruction was 22.3 and in patients with Proximal obstruction was 18.09. The highest recorded biliary pressure was 52 in periampullary carcinoma. Conclusions: First study of its kind to document the biliary pressure and the bile characteristics in obstructive jaundice of various etiologies.

MUC1, CK20, and CDX2 immunohistochemical markers can sub-classify periampullary carcinomas into pancreaticobiliary, intestinal, and mixed subtypes.

Pancreaticobiliary subtype of Periampullary carcinoma (PAC) has a poor prognosis in comparison to the intestinal subtype. We assessed the potential of cytokeratins and mucin markers to classify the sub-types of periampullary tumors and compared them with the survival data to identify markers that may predict prognosis. PAC tumor tissues were obtained from 94 patients undergoing Whipples Pancreaticoduodenectomy. Paraffin-embedded tissues were immunostained with cytokeratins CK7, CK20), mucins (MUC1, MUC2, MUC5Ac), and CDX2 antibodies. The survival status of patients was obtained as follow-up up to 5-years of surgery. The Receiver Operating Character Curve (ROC) analysis was used for detecting sensitivity and specificity. The survival data were analyzed using the Kaplan-Meier survival curve. Tumors were initially categorized on the basis of histological classification as pancreaticobiliary (n = 46), intestinal (n = 35) and indeterminate (n = 13). Further, using immunohistochemical markers (MUC1, CK20, and CDX2), we gave systematic classification of IHC-PB (n = 51), IHC-Int (n = 30) and IHC-Mixed (n = 13). The interobserver analysis showed good agreement between histologic and IHC type with a kappa value of 0.554. Combined expression of CK20, MUC1 and CDX2 accurately classify the mixed type of tumor. Overall survival rate and duration were 74.4% and 44.95 ± 2.29 months. Survival analysis for subtypes reveal, pancreaticobiliary tumors have low survival (27.9 ± 1.63 months) than mixed type (35.5 ± 0.45 months) and intestinal-type (52.92 ± 2.18 months). Among these, intestinal-type have better survival. Only TNM Stage III (tumor staging as per American Joint Committee on Cancer classification) and perineural invasion have been associated with predicting poor survival in PAC patients. Our results suggest that the combined expression of MUC1, CK20 and CDX2 could serve as markers to diagnose histological inconclusive specimens as mixed subtype tumors.

Clinicopathological Outcome of Patients Undergoing Whipple’s Operation- A Retrospective Study over a Decade in a Tertiary Care Centre

Introduction: The surgical procedure pancreaticoduodenectomy is popularly known as Whipple’s operation. Whipple procedure is one of the major surgeries performed in tertiary care centres. Aim: The present research was undertaken to study indications of Whipple’s operation and also to evaluate pathological findings of periampullary tumours with biochemical investigations. Materials and Methods: This retrospective study was conducted in total 155 patients who had undergone Whipple’s operation over a period of ten years from January 2009 to December 2019 at a tertiary care hospital in a central India. The hematoxylin and Eosin (H&amp;E) stained slides were reviewed and various parameters were studied like presence or absence of the tumour, site of origin of tumour (ampulla/ head of pancreas/distal common bile duct/ duodenum), histological type (adenocarcinoma/neuroendocrine/ lymphoma), differentiation (well/moderate/poor), depth of invasion, Lymphovascular Invasion (LVI), perineural infiltration, lymph node status (metastasis), resection margin status (involved/not involved) and {Tumour (T), Nodes (N), Metastasis (M)} staging. Perioperative complications and postoperative follow-up of minimum 30 days for all patients were studied. Results: The most common indication for Whipple’s operation was periampullary carcinoma irrespective of its site of origin and was most commonly seen in males in age group of 51-60 years. Out of total 155 cases, four cases were excluded as no tumours were found in those cases. Tumours from ampulla were most common (101) followed by those from Common Bile Duct (CBD) (22) and pancreas (22) and duodenum (6). The median size of the tumour in Whipple's specimen was 1.44 cm2. Most frequent histological type was adenocarcinoma (145, 96.02%). Moderate differentiation was most commonly observed histological grade in periampullary carcinomas 116 (76.8%). Perineural and lymphovascular infiltration was seen more commonly in pancreatic cancers 90.9% (20/22). Lymph node metastasis was significantly high in pancreatic cancers. Perioperative complications were seen in 32 patients with common complications were biliary leak. The perioperative mortality was 7.9%. Distal cholangiocarcinoma was found to be more aggressive followed by pancreatic and ampullary cancers. Conclusion: Whipple procedure is associated with a unique set of common complications and continues to be associated with considerable morbidity. With careful patient selection, Whipple procedure can be performed safely.

Minimally Invasive Pancreaticoduodenectomy (MIPD) at a Tertiary Centre over 2 Decades- "Lessons Learnt & Techniques Modified"

Introduction: In 1998, the first totally Laparoscopic pancreaticoduodenectomy (LPD) for periampullary carcinoma was performed in our institute. 22 years since then ,MIPD at our institute has undergone several technical modifications, the recent addition ,over the last 2 years being Robotic Pancreaticoduodenectomy (RPD). Lessons learnt and techniques modified in this journey over the past 2 decades have been presented. Methods: A retrospective analysis of prospectively maintained database was carried out for all MIPD cases (418 LPD & 42 RPD ) done at our institute from Dec 1998 to Dec 2019. A subgroup analyses was done to compare the outcomes of LPD in the first decade versus the second decade. Results: The authors observed a reduction in operative time and estimated blood loss between the first decade and the second decade. The mean number of lymph nodes removed was higher in the second decade , though not statistically significant (p= 0.07) Estimated blood loss was comparable with laparoscopic and robotic PD (203.23+/- 84.37 vs 206.17 +/- 82.82, p=0.87) However robotic PD took a significantly longer time compared to LPD (392 +/- 124.26 vs 312 +/- 39.62 , p=0.02) in this series. Conclusion: MIPD provides several advantages like decreased length of hospitalization, reduced blood loss and need for transfusion, more meticulous oncologic dissection and higher lymph node yield. Accumulation of surgical experience, better optics, improved energy sources and adoption of robotic technology have refined the outcomes of MIPD at our institute and worldwide, in recent times.

Pancreatoduodenectomy for Ampullary Cancer after Roux-en-Y Gastric Bypass – An Extremely Rare Case Report

Introduction: Obesity is a known risk factor for periampullary carcinoma. However we have identified in the international literature only 1 case of a patient with ampullary carcinoma and history of gastric bypass submitted to curative surgery. And it is considered a surgery challenge. We present here the second case. Methods: This clinical case describes a female patient, 70 years old, clinically classified as a periampullary neoplasia with resectability criteria and without metastization evidence (cT2N0M0). This patient has a surgical history of a laparoscopic Roux-en-Y gastric bypass in 2017. This clinical case was discussed in the multidisciplinary hepatobilopancreatic meeting, resulting in a curative surgery as proposal. Results: The patient was subjected to a pancreatoduodenectomy (with a terminolateral pancreatojejunal anastomosis and a terminolateral hepaticojejunal anastomosis) with remnant gastrectomy in December of 2020. Postoperative care had no complications, resulting in a clinical discharge thirteen days later. The histological result of the surgical piece showed an ampullary adenocarcinoma moderately differentiated with invasion of peripancreatic adipose tissue, with surgical margins free of neoplasia and 29 nodes were removed (6 with metastasis) (pT4, pN1). Conclusion: There are multiple types of possible reconstruction for patients after a Roux-en-Y gastric bypass. The rarity of clinical cases is the main factor for the poor evidence to the best clinical practice and for the big surgical challenge that it presents.

MR CHOLANGIO-PANCREATICOGRAPHY AS A TOOL FOR EVALUATION OF PATIENTS WITH PANCREATICOBILIARY DISEASES

Objectives Of Study: 1. To describe features of pancreaticobiliary diseases on MRCP. 2. Outlining the extent in terms of involvement of adjacent structures, vessels
and soft tissues. 
 3. To help in deciding further course of management. 4. To identify the anatomical variants. 
 5. To prove the Magnetic Resonance Cholangio-Pancreatography (MRCP) is
one of the best imaging modality for evaluation of pancreatico-biliary disease. Material And Methods:The present study was undertaken to evaluate the role of MRCP in evaluation of pancreaticobiliary diseases. The study will be done on patients presenting with features suggestive of pancreatico-biliary diseases attending the OPD or admitted in various wards of Krishna Rajendra hospital, Mysore attached to Mysore Medical College &amp; Research Institute, Mysore. A total of 30 patients were included in our study. Result:Majority of patients in study population were males (60%) while 40% were females. The mean age of the study sample was 37.5 years and maximum numbers of cases were observed in age group of &gt; 40 years. Majority of pathologies observed were benign 18(60%). Pancreatitis was the most common finding (33.3%) followed by Cholangiocarcinoma (20%), Choledocholithiasis (13.4%), Periampullary carcinoma (10%), Ca. Pancreas (6.7%) &amp; Choledochal cyst (6.7%).Pancreatitis is common in males followed by Cholangiocarcinoma, which is common in both males &amp; females.Both benign &amp; malignant strictures have equal predominance. Both benign &amp; malignant strictures are common in proximal CBD. Conclusion: MRCP is non-invasive, non-ionizing imaging method for evaluation of pancreatico-biliary anatomy and pathology. It is superior diagnostic modality in detection and characterization of pancreatico-biliary pathologies.

Cytokeratin-positive cells in the bone marrow from patients with pancreatic, periampullary malignancy and benign pancreatic disease show no prognostic information

BackgroundPancreatic and periampullary carcinoma are aggressive tumours where preoperative assessment is challenging. Disseminated tumour cells (DTC) in the bone marrow (BM) are associated with impaired prognosis in a variety of epithelial cancers. In a cohort of patients with presumed resectable pancreatic and periampullary carcinoma, we evaluated the frequency and the potential prognostic impact of the preoperative presence of DTC, defined as cytokeratin-positive cells detected by immunocytochemistry (ICC).MethodsPreoperative BM samples from 242 patients selected for surgical resection of presumed resectable pancreatic and periampullary carcinoma from 09/2009 to 12/2014, were analysed for presence of CK-positive cells by ICC. The median observation time was 21.5 months. Overall survival (OS) and disease-free survival (DFS) were calculated by Kaplan-Meier and Cox regression analysis.ResultsSuccessful resections of malignant tumours were performed in 179 of the cases, 30 patients resected had benign pancreatic disease based on postoperative histology, and 33 were deemed inoperable intraoperatively due to advanced disease. Overall survival for patients with resected carcinoma was 21.1 months (95% CI: 18.0–24.1), for those with benign disease OS was 101 months (95% CI: 69.4–132) and for those with advanced disease OS was 8.8 months (95% CI: 4.3–13.3). The proportion of patients with detected CK-positive cells was 6/168 (3.6%) in resected malignant cases, 2/31 (6.5%) in advanced disease and 4/29 (13.8%) in benign disease. The presence of CK-positive cells was not correlated to OS or DFS, neither in the entire cohort nor in the subgroup negative for circulating tumour cells (CTC).ConclusionsThe results indicate that CK-positive cells may be present in both patients with malignant and benign diseases of the pancreas. Detection of CK-positive cells was not associated with differences in prognosis for the entire cohort or any of the subgroups analysed.Trial registrationclinicaltrials.gov (NCT01919151).

USPIO-enhanced MRI for pre-operative lymph node staging in patients with pancreatic and periampullary carcinoma: a feasibility study

USPIO-enhanced MRI for pre-operative lymph node staging in patients with pancreatic and periampullary carcinoma: a feasibility study

ARTERIAL RESECTION IN PANCREATIC CANCER SURGERY: A SINGLE-CENTER EXPERIENC

Pancreaticoduodenal resection (PDR) with vascular reconstruction is performed in approximately 20 % of pancreatic cancer patients. The superior mesenteric vein resection and reconstruction has become a standard routine surgery, whereas arterial resection during pancreatic surgery is still an issue of controversial debate.The purpose of the study was to evaluate short-and long-term outcomes of PDR with reconstruction of various arteries.Material and Methods. Outcomes of 89 PDRs and pancreaticoduodenectomies performed in patients with stage II–IV periampullary carcinoma were assessed. The average age of the patients was 63.1 ± 8.2. There were 18 (20.2 %) PDRs with vascular reconstruction, of them 7 (7.8 %) were arterial resections.Results. In patients who underwent artery resection (n=7), complications were observed in 5 (71.4 %) cases. Out of 71 patients who underwent PDR without arterial and/or venous resection, 29 (40.8 %) had complications (p=0.229). The postoperative mortality rates were 1 (14.3 %) and 3 (4.2 %), respectively (p=0.319). The median disease-free survival was 5.0 months (95 % CI 2.4–7.6 months) in the arterial resection group and 12.3 months (95 % CI 9.2–15.4 months) in the standard surgery group (log-rank test, p=0,011). The median overall survival was 8.0 months (95 % CI 3.7–12.3 months) in the in the arterial resection group and 21.8 months (95 % CI 15.9–27.7 months) in the standard surgery group (log-rank test, p=0.011).Conclusion. The disease-free and overall survival rates were significantly worse in the arterial resection group than in the standard surgery group. This is most likely due to a small sample of patients. Further studies are needed to analyze the immediate and long-term treatment outcomes of PDR with arterial resection for pancreatic cancer.

The Impact of Adjuvant Chemoradiotherapy on the Overall Survival of Completely Resected Ampullary and Periampullary Carcinoma: An Updated Meta-Analysis

Ampullary and Periampullary carcinomas (APAC) are uncommon gastrointestinal cancers that are often amenable to surgical resection. The benefit of postoperative adjuvant chemoradiotherapy (ACRT) in patients with completely resected localized AC has been controversial. A meta-analysis which was conducted in 2017 found no associated survival benefit for adjuvant therapies in APAC. However, this meta-analysis combined studies that used adjuvant chemotherapy alone with those that used ACRT. The purpose of this meta-analysis is to evaluate the impact of ACRT on the overall survival (OS) of patients with completely resected APAC incorporating more recent studies. A review of the medical literature was conducted using online databases. Inclusion criteria consisted of (i) resected Ampullary and Periampullary carcinoma (ii) English language (iii) publication date starting 1999 to the present, (iv) studies reporting OS with hazard ratios (HR) or Kaplan-Meier curves of patients that underwent ACRT versus those that did not, and (v) studies that reported the aggregate OS data of adjuvant therapies where the preponderance of the cohort received ACRT. Adjuvant chemotherapy studies and those that reported aggregate OS for a cohort with a preponderance of adjuvant chemotherapy were excluded. A meta-analysis was conducted using an inverse variance method with a random-effects model. Sixteen studies that included 1,122 patients treated with ACRT were analyzed. The majority of APAC patients that received ACRT tended to have high-risk features. These high-risk features included T3/T4 primary tumors, positive regional lymph nodes, poor histologic differentiation, and positive resection margins. Four of these studies analyzed their OS data for the high-risk APAC patients in addition to the cohort as a whole. Intra-arterial chemotherapy and concomitant radiotherapy were used in one study. ACRT was found to be significantly associated with OS benefit in patients with completely resected APAC (HR 0.76, 95%CI: 0.65-0.88, p<0.001) with an inconsistency estimate, I2 = 37% (95%CI: 0-65). This is the first meta-analysis to show that adjuvant chemoradiotherapy is associated with a survival benefit in patients with completely resected high risk Ampullary and Periampullary carcinoma. In the absence of randomized clinical trials, this meta-analysis represents the most compelling data supporting the use of ACRT in this patient population.

Feasibility and safety of bedside percutaneous biliary drainage in patients with severe cholangitis.

PurposeTo evaluate the safety and feasibility of bedside percutaneous transhepatic biliary drainage (PTBD) as a salvage procedure in patients with severe cholangitis in the intensive care unit (ICU).MethodsThis retrospective study evaluated records of consecutive patients with severe cholangitis who were admitted in the ICU. Bedside PTBD was performed using ultrasound guidance. The level and cause of biliary obstruction were recorded. The technical success of the procedure and complications were recorded.ResultsTen patients (six males, mean age 53.8 years) underwent bedside PTBD. Six patients had distal common bile duct blockade [periampullary carcinoma (n = 2), carcinoma pancreas (n = 2), choledocholithiasis (n = 1), and benign stricture (n = 1)]. Four patients had malignant hilar stricture [cholangiocarcinoma (n = 3) and carcinoma gallbladder (n = 1)]. Technical success was achieved in all. One patient underwent bilateral PTBD. Left and right PTBD were performed in 5 and 4 patients, respectively. There were no major complications. Transient hemobilia occurred in two patients.ConclusionBedside PTBD is safe and technically feasible. Prospective studies are required to establish this procedure into routine clinical practice.

Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer

BackgroundPancreaticoduodenectomy (PD) is more challenging in the elderly. MethodsData of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL). ResultsOut of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients. ConclusionAlthough PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.

Relationship Between Quality of Life and Survival in Patients With Pancreatic and Periampullary Cancer: A Multicenter Cohort Analysis.

A relationship between quality of life (QoL) and survival has been shown for several types of cancer, mostly in clinical trials with highly selected patient groups. The relationship between QoL and survival for patients with pancreatic or periampullary cancer is unclear. This study analyzed QoL data from a prospective multicenter patient-reported outcome registry in patients with pancreatic or periampullary carcinoma registered in the nationwide Netherlands Cancer Registry (2015-2018). Baseline and delta QoL, between baseline and 3-month follow-up, were assessed with the Happiness, EORTC Quality of Life Questionnaire-Core 30 (QLQ-C30), and QLQ-PAN26 questionnaires. The relationship between QoL and survival was assessed using Cox regression models, and additional prognostic value of separate items was assessed using Nagelkerke R2 (explained variance). For the baseline and delta analyses, 233 and 148 patients were available, respectively. Most were diagnosed with pancreatic adenocarcinoma (n=194; 83.3%) and had stage III disease (n=77; 33.0%), with a median overall survival of 13.6 months. Multivariate analysis using baseline scores indicated several scales to be of prognostic value for the total cohort (ie, happiness today, role functioning, diarrhea, pancreatic pain, and body image; hazard ratios all P<.05) and for patients without resection (ie, overall satisfaction with life, physical and cognitive functioning, QLQ-C30 summary score, fatigue, pain, constipation, diarrhea, and body image; hazard ratios all P<.05). Except for diarrhea, all QoL items accounted for >5% of the additional explained variance and were of added prognostic value. Multivariate analysis using delta QoL revealed that only constipation was of prognostic value for the total cohort, whereas no association with survival was found for subgroups with or without resection. In a multicenter cohort of patients with pancreatic or periampullary carcinoma, QoL scores predicted survival regardless of patient, tumor, and treatment characteristics. QoL scores may thus be used for shared decision-making regarding disease management and treatment choice.

Clinical Utility of Symptoms and Serum Carbohydrate Antigen (CA) 19-9 for Detection of Recurrence after Curative Intent Resection of Periampullary Carcinoma

Amburn, Thomas L. BA; Ginn, Madison BS; Patel, Reema MD; Krishnan Pandalai, Prakash MD, FACS; Kim, Joseph MD, FACS; Joseph Cavnar, Michael MD Author Information

Chemoradiation in Periampullary Carcinoma after Whipple’s Pancreatico-duodenectomy

The role of adjuvant chemoradiation in periampullary carcinoma after Whipple’s pancreatico-duodenectomy is not well defined. The aim of this audit was to evaluate the efficacy of adjuvant chemoradiation after Whipple’s pancreatico-duodenectomy in periampullary carcinoma. Between January 1991 to December 2016, the 151 curatively resected patients of periampullary carcinoma were prospectively planned for adjuvant chemoradiation. All patients were planned for adjuvant external beam radiotherapy to a dose of 45-50.4 Gy/ 25-28 fractions in 5-5½ weeks to tumor bed and lymph node drainage area along with either 5-fluorouracil(5-FU) 370mg/m2 I.V. weekly or day 1-5 at 4 weekly or oral Capecitabine 1650mg/m2 daily delivered concurrently during radiation therapy and as adjuvant following completion of radiation therapy. The results were analyzed in October 2019. Of the 151 patients with resected periampullary carcinoma, there were 104 males and 47 females and size of tumor ranges from 0.5 cm to 8 cm(median =2 cm). The median age of patients was 52 years. ; 127 (84 %) were ampullary tumors and 24 (16 %) were non-ampullary including duodenum and distal bile duct. Based on histology and operative findings (such as poorly differentiated histology, positive surgical margin, lymph node positivity and /or pancreatic infiltration) the patients were categorized into high risk group (n= 131, 86.8%) and remaining in low risk group (n=20, 13.2%). The 5-FU chemotherapy (weekly/monthly) was given in 112 patients (74.2%) while oral Capecitabine was given in 20 patients(13.2%) and 19 patients (12.6%) received no chemotherapy and radiation therapy. The median and 5-year overall survival in whole group was 26 months and 26%. According to risk categorization, in low risk group and high-risk group the median survival is 31 vs. 26 months and 5-year Overall is 40% vs. 23.6 % respectively; p-value = 0.19). Among high risk group, 113 patients received chemoradiation and 18 did not. The 5-year OS in this high risk group treated with chemoradiation is 26% vs. 5.6% without RT (p=0.30) and median survival is 27 vs. 21 months respectively. Chemoradiation Toxicities were assessed in all 132 patients who received adjuvant treatment. Two patients died of acute hematological toxicity of chemoradiation during treatment. Local recurrence (37%) followed by distant metastasis to liver and other sites (20.5%) were predominant site of failure and 20% died of other non- specific causes and 4 died of chronic radiation gastroduodenitis with gastrointestinal bleeding with intestinal obstruction, out of them, two had necrosis and perforation of duodenum. Adjuvant chemoradiation is effective and well tolerated in high risk periampullary carcinoma and improves the overall survival, although no significant difference was found between chemoradiation and non chemoradiaion group as number of patients in non RT group were very few.