S3651 Dual Structural Abnormalities in the Periampullary Region Causing Acute Pancreatitis: A Case Report

Background: Malignant gastric outlet obstruction (GOO) is a common complication of stomach, pancreas, and periampullary region tumors, causing serious nutritional disorders and loss of quality of life. This study evaluated the clinical data and factors affecting the survival of patients who underwent palliative gastroenterostomy. Methods: Data from 23 patients who underwent palliative gastroenterostomy due to malignant gastric outlet obstruction in our center between June 2020 and January 2025 were analyzed retrospectively. Demographic characteristics, preoperative clinical data, intraoperative findings, and postoperative outcomes of the patients were evaluated. Patients were divided into two groups according to their survival times as below and above 90 days; factors affecting survival were analyzed by Kaplan-Meier curves and Cox regression analyses. Results: Patients who lived longer than 90 days had higher Karnofsky Performance Score, lower Charlson Comorbidity Index, higher albumin level, and preserved electrolyte balance (p

Abstract. Introduction. Pancreatoduodenectomy (PD) is the primary surgical approach for treating malignant and select benign tumors of the pancreas and periampullary region. One of the most serious complications following PD is post-pancreatectomy acute pancreatitis (PPAP), which significantly impacts postoperative outcomes and patient prognosis. Identifying the risk factors associated with PPAP is crucial for optimizing surgical strategies, which was the primary objective of this study. Materials and methods. A retrospective analysis of 296 pancreatoduodenectomy cases was conducted, with patients categorized into two groups: those who developed PPAP (n=126) and those who did not (n=170). A comparative analysis of key intraoperative parameters was performed, along with a multivariate logistic regression analysis to determine the primary predictors of PPAP development. The analysis incorporated patient morphofunctional characteristics and technical aspects of the surgical procedure. Key factors influencing the risk of PPAP were identified. Results. Intergroup analysis demonstrated that patients with PPAP had a significantly higher body mass index (BMI) than those without PPAP (25,6 vs. 24,9, p=0,03). Among the surgical factors, the greatest impact on PPAP development was associated with the type of pancreatic anastomosis, portal vein resection, main pancreatic duct diameter, and pancreatic consistency. Specifically, pancreatogastrostomy was associated with an increased risk of PPAP (84,1% vs. 73,5%, p=0,03), while pancreatojejunostomy was associated with a lower incidence of this complication (15,9% vs. 26,5%, p=0,03). Portal vein resection significantly reduced the risk of PPAP by 2,81 times (p=0,005). A wider main pancreatic duct diameter (>3 mm) was also correlated with a lower risk (31,6% vs. 63,1%, p<0,0001). Conversely, a soft pancreatic texture markedly increased the likelihood of PPAP (79,6% vs. 38,4%, p<0,0001). The findings indicate that the choice of pancreatic remnant reconstruction technique, morphological characteristics of the pancreas, and technical aspects of the procedure substantially influence the incidence of PPAP. A soft pancreatic parenchyma was identified as the most significant predictor of this complication, while portal vein resection and a wider main pancreatic duct diameter were protective factors. These insights highlight the need to adapt surgical strategies to minimize postoperative complications following PD. Conclusions. The main risk factors for PPAP following PD include an elevated BMI (p=0,03), pancreatogastrostomy (p=0,03), a narrow main pancreatic duct diameter (p<0,0001), and a soft pancreatic texture (p<0,0001). Portal vein resection was significantly more common in patients without PPAP (p=0,004). Multivariate analysis identified three independent predictors of PPAP following PD: pancreatic texture (OR=4.40; p=0.001), main pancreatic duct diameter (OR=3.10; p=0.005), and intraoperative portal vein resection (OR=2.21; p=0.02).

Beyond the Common: A Pictorial Review of Rare and Atypical Periampullary Lesions.

Annotation Pancreatoduodenectomy is the only treatment method for patients with pancreatic head and periampullary region tumors. It is known that some long-lived patients develop exocrine pancreatic insufficiency after surgery. One of the consequences of exocrine pancreatic insufficiency is fatty liver disease, which has been reported to occur in 7.8% to 40.0% of patients after pancreatoduodenectomy. We reported two clinical cases of patients who underwent pancreatoduodenectomy and total pancreatectomy for pancreatic head cancer and intraductal papillary mucinous neoplasm of the main pancreatic duct. After surgery, they developed rapidly progressive fatty liver disease with no history of liver disease, leading to death from liver failure 20 days and 3 months after surgery. Severe malnutrition caused by exocrine pancreatic insufficiency, postoperative eating disorders, and exacerbation of diabetes mellitus were the main factors contributing to the rapid deterioration of the condition. This clinical case highlights the possibility of developing life-threatening fatty liver disease with severe fibrosis after pancreatoduodenectomy and total pancreatectomy. Careful monitoring of liver status, regular nutritional assessment of patients, prophylactic replacement of pancreatic enzymes, and ensuring adequate nutrition are important.

Aim - to evaluate the feasibility and safety of venous resections (VR) during pancreatoduodenectomy (PD) in patients with malignant tumors of the periampullary region. Materials and methods. A retrospective cohort study was conducted, including 111 patients who underwent PD for malignant tumors of the periampullary region between 2018 and 2023. Patients were divided into two groups: with and without VR. Statistical analysis was performed to compare mean values and assess postoperative complications using the Clavien-Dindo classification. Results. Mean blood loss, operative time, rates of complications, delayed gastric emptying, postoperative pancreatic fistula, hospital and 30-day mortality did not differ significantly between the groups. Median overall survival was 22 months in the VR group and 37 months in the non-VR group; the 5-year survival rates were 22.2% and 35.9%, respectively. Conclusions. PD with VR is a safe and feasible procedure for patients with tumor invasion of major veins. The inclusion of VR does not significantly increase risks or worsen postoperative outcomes. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee for all participants. The informed consent of the patients was obtained for the study. The authors declare no conflict of interest.

Collision tumors are rare neoplasms composed of two histologically distinct components without a transitional zone. Only nine cases involving periampullary adenocarcinoma and neuroendocrine tumor (NET) have been reported. A 55‐year‐old male presented with recurrent fever and jaundice. Imaging and biopsy revealed a periampullary lesion diagnosed as tubule‐villous adenoma with high‐grade dysplasia. He underwent pylorus‐preserving pancreatoduodenectomy. Histology revealed moderately differentiated intestinal‐type adenocarcinoma (pT2N1) with regional lymph node metastasis. Additionally, a 2‐mm well‐differentiated NET was found 2.5 cm proximal to the primary tumor, also with nodal metastasis. Immunohistochemistry confirmed distinct lineages, fulfilling the criteria for a collision tumor. This case represents a rare periampullary collision tumor with both adenocarcinoma and NET components showing independent lymph node metastases. The absence of transitional zones rules out MiNEN. This report underscores the importance of thorough pathological assessment and adds to the limited literature on the behavior and prognosis of periampullary collision tumors.

Prevention of Postoperative Pancreatic Fistula and Other Complications in Patients with Pancreatic and Periampullary Region Cancer Following Pancreatoduodenectomy

Pancreatic cancer is an aggressive malignancy with many cases diagnosed at locallyadvanced stagesmakingpancreaticoduodenectomya technically challenging surgery with significant mortality and morbidity. This study analyses the surgical outcomes and survival after surgery for pancreatic cancers from a single centre in south India. This is a retrospective analysis of pancreatic and periampullary cancer patients who were treated in our institute between January 2014 and November 2022 (n = 71). The median ageat diagnosiswas 55years. In about 2/3rd of cases, tumour was located in periampullary region and 62 out of 71 patients underwent curative resection. The most common histopathological diagnosis was adenocarcinoma (87%). Nodal metastasis were detected in 13% of specimens. The predominant morbidity was delayed gastric emptying (DGE 12.7%) and clinically relevant postoperative pancreatic fistula (CR-POPF 11%) with a combined overall morbidity of 35.2% and 30-day mortality of 7.3%. Pre-op nutritional status had astrong association with postoperative morbidity. The median time of survival was 20months, with a median follow-up of 22months. Age less than 60years (P value = 0.0264) and receivingall 6 or more cycles of chemo were significantly associated with improved survival (P value = 0.0297). Lower-stage cancers (T1, T2, and N0) were associated with better survival. The patient characteristics, histological factors, and perioperative outcomes were similar to the reports from other Indian studies. The 3-year survival rate was 30%. There was an increasing trend of survival in patients with age less than 60years and in patients who received 6 or more cycles of chemotherapy.

Abstract Breast cancer is the most common malignancy in females and the leading cause of mortality in females among all malignancies. Distant metastasis to the bone, lungs, liver, and brain are commonly found in them, but gastrointestinal involvement is rare. Direct extrahepatic involvement without the liver is exceptional, and we report one of these rare cases that presented with obstructive jaundice due to metastasis from breast cancer to the periampullary region. This case emphasizes the role of tissue histopathology and immunochemistry profile to include the possibility of biliary localization of metastasis from primary breast cancer as a differential diagnosis of obstructive jaundice.

Introduction Whipple’s pancreaticoduodenectomy has become a widely used resection procedure for pancreatic head, periampullary, ampullary, and biliary tumors. This study was conducted to analyze the histopathological features of these tumors in pancreaticoduodenectomy specimen. MethodsA descriptive study was carried out in the Pathology Department of Kathmandu Medical College Teaching Hospital. Pancreaticoduodenectomy specimens received were assessed for tumor location, histopathologic categorization, grading, lymphovascular and perineural invasion, margin status, and lymph node status. AJCC TNM staging was done. ResultsOut of 41 Whipple's pancreaticoduodenectomy cases, 35 (85.4%) were malignant and 6 (14.6%) were benign. The patients' ages ranged from 30 to 84 years, with a mean age of 58.3 years and a male to female ratio of 1.2:1. Adenocarcinoma was the most common malignant lesion (73.2%; n=30) frequently found in the intra-ampullary and periampullary regions (31.4%; n=11). The intestinal type of adenocarcinoma was the most common (42.8%; n=15), followed by the pancreaticobiliary type (34.3%; n=12). Most tumors were moderately differentiated (74.3%; n=26). Perineural invasion was frequently seen in intra-ampullary and periampullary carcinoma (81.8%; n=9). Lymphovascular invasion was frequently seen in intra-ampullary and periampullary carcinoma (81.8%; n=9). Most tumors were in the T3 stage (42.9%; n=15), and overall nodal metastasis (N1 and N2) was seen in 57.1% (n=20). ConclusionAdenocarcinoma was the commonest diagsosis in pancreaticoduodenectomy specimens of the intra-ampullary and periampullary region. Malignant lesions were more frequent than benign lesion in our study.

ObjectiveRare but aggressive cancer types like non-pancreatic periampullary cancers pose unique challenges for cancer research due to their low incidence rates and lack of consensus on optimal treatment strategies, therefore necessitating a collaborative approach. The International Study Group on non-pancreatic peri-Ampullary CAncer (ISGACA) aimed to build a collaborative initiative to pool expertise, funding opportunities, and data from over 60 medical centers, in order to improve outcomes for underrepresented patients with rare cancers. MethodsThe ISGACA approach predefined a stepwise approach including a research scope, establishing a dedicated steering committee, creating a recognizable brand, identifying research gaps, following a well-defined timeline, ensuring robust data collection, addressing legal and ethical considerations, securing financial resources, investing in research ethics training and statistical expertise, raising awareness, creating uniformity, and initiating prospective studies. ResultsOverall, 60 medical centers joined the ISGACA consortium (41 in Europe, 15 in North-America, three in Asia, one in Australia). The database includes 4309 patients. Nine publications and several ongoing studies which in turn allowed for a successful application of research grants. Subsequently, an international consensus meeting established uniform definitions and classifications, and one prospective multicenter international clinical trial has been initiated. ConclusionBy sharing knowledge, expertise, and clinical data, the ISGACA approach has not only gathered sufficient evidence to secure grants and ethical approvals for prospective studies, but also demonstrates options for standardizing patient care and improving outcomes for patients with rare cancers. The ISGACA approach offers a detailed methodology for initiating research on rare cancers and could serve as a replicable model for future research initiatives.

BackgroundPancreatoduodenectomy is the only cure for cancers of the pancreas and the periampullary region but has considerable operative complications and uncertain prognosis. Our goal was to analyse temporal improvements and provide contemporary population-based benchmarks for outcomes following pancreatoduodenectomy.MethodsWe empanelled a cohort comprising all patients in Sweden with pancreatic or periampullary cancer treated with pancreatoduodenectomy from 1964 to 2016 and achieved complete follow-up through 2016. We analysed postoperative deaths and disease-specific net survival.ResultsWe analysed 5923 patients with cancer of the pancreas (3876), duodenum (444), bile duct (504), or duodenal papilla (963) who underwent classic (3332) or modified (1652) Whipple’s procedure or total pancreatectomy (803). Postoperative deaths declined from 17.2% in the 1960s to 1.6% in the contemporary time period (2010–2016). For all four cancer types, median, 1-year and 5-year survival improved substantially over time. Among patients operated between 2010 and 2016, 5-year survival was 29.0% (95% confidence interval (CI): 25.5, 33.0) for pancreatic cancer, 71.2% (95% CI: 62.9, 80.5) for duodenal cancer, 30.8% (95% CI: 23.0, 41.3) for bile duct cancer, and 62.7% (95% CI: 55.5, 70.8) for duodenal papilla cancer.ConclusionThere is a continuous and substantial improvement in the benefit-harm ratio after pancreatoduodenectomy for cancer.

ObjectivesTo assess 3-Tesla (3-T) ultra-small superparamagnetic iron oxide (USPIO)-enhanced MRI in detecting lymph node (LN) metastases for resectable adenocarcinomas of the pancreas, duodenum, or periampullary region in a node-to-node validation against histopathology.MethodsTwenty-seven consecutive patients with a resectable pancreatic, duodenal, or periampullary adenocarcinoma were enrolled in this prospective single expert centre study. Ferumoxtran-10-enhanced 3-T MRI was performed pre-surgery. LNs found on MRI were scored for suspicion of metastasis by two expert radiologists using a dedicated scoring system. Node-to-node matching from in vivo MRI to histopathology was performed using a post-operative ex vivo 7-T MRI of the resection specimen. Sensitivity and specificity were calculated using crosstabs.ResultsEighteen out of 27 patients (median age 65 years, 11 men) were included in the final analysis (pre-surgery withdrawal n = 4, not resected because of unexpected metastases peroperatively n = 2, and excluded because of inadequate contrast-agent uptake n = 3). On MRI 453 LNs with a median size of 4.0 mm were detected, of which 58 (13%) were classified as suspicious. At histopathology 385 LNs with a median size of 5.0 mm were found, of which 45 (12%) were metastatic. For 55 LNs node-to-node matching was possible. Analysis of these 55 matched LNs, resulted in a sensitivity and specificity of 83% (95% CI: 36–100%) and 92% (95% CI: 80–98%), respectively.ConclusionUSPIO-enhanced MRI is a promising technique to preoperatively detect and localise LN metastases in patients with pancreatic, duodenal, or periampullary adenocarcinoma.Clinical relevance statementDetection of (distant) LN metastases with USPIO-enhanced MRI could be used to determine a personalised treatment strategy that could involve neoadjuvant or palliative chemotherapy, guided resection of distant LNs, or targeted radiotherapy.RegistrationThe study was registered on clinicaltrials.gov NCT04311047. https://clinicaltrials.gov/ct2/show/NCT04311047?term=lymph+node&cond=Pancreatic+Cancer&cntry=NL&draw=2&rank=1.Key PointsLN metastases of pancreatic, duodenal, or periampullary adenocarcinoma cannot be reliably detected with current imaging.This technique detected LN metastases with a sensitivity and specificity of 83% and 92%, respectively.MRI with ferumoxtran-10 is a promising technique to improve preoperative staging in these cancers.

Cancer arising in the periampullary region can be anatomically classified in pancreatic ductal adenocarcinoma (PDAC), distal cholangiocarcinoma (dCCA), duodenal adenocarcinoma (DAC), and ampullary carcinoma. Based on histopathology, ampullary carcinoma is currently subdivided in intestinal (AmpIT), pancreatobiliary (AmpPB), and mixed subtypes. Despite close anatomical resemblance, it is unclear how ampullary subtypes relate to the remaining periampullary cancers in tumor characteristics and behavior. This international cohort study included patients after curative intent resection for periampullary cancer retrieved from 44 centers (from Europe, United States, Asia, Australia, and Canada) between 2010 and 2021. Preoperative CA19-9, pathology outcomes and 8-year overall survival were compared between DAC, AmpIT, AmpPB, dCCA, and PDAC. Overall, 3809 patients were analyzed, including 348 DAC, 774 AmpIT, 848 AmpPB, 1,036 dCCA, and 803 PDAC. The highest 8-year overall survival was found in patients with AmpIT and DAC (49.8% and 47.9%), followed by AmpPB (34.9%, P < 0.001), dCCA (26.4%, P = 0.020), and finally PDAC (12.9%, P < 0.001). A better survival was correlated with lower CA19-9 levels but not with tumor size, as DAC lesions showed the largest size. Despite close anatomic relations of the five periampullary cancers, this study revealed differences in preoperative blood markers, pathology, and long-term survival. More tumor characteristics are shared between DAC and AmpIT and between AmpPB and dCCA than between the two ampullary subtypes. Instead of using collective definitions for "periampullary cancers" or anatomical classification, this study emphasizes the importance of individual evaluation of each histopathological subtype with the ampullary subtypes as individual entities in future studies.

Duodenopancreatectomía cefálica tipo Whipple versus duodenopancreatectomía con preservación pilórica. Estudio retrospectivo

Pancreatic cancers usually metastasize through the lymphoid system to organs such as the lung, liver, bone and spleen. Ovarian metastasis in pancreatic cancers is extremely rare, hence, it is difficult to distinguish between primary and metastatic ovarian tumors, especially in tumors with a primary source from the GIT &amp; Hepatobiliary system. We present the case of a periampullary carcinoma with ovarian metastasis in a middle-aged female who presented with complaints of abdominal pain, constipation, yellowish discoloration of eyes and dark colored urine along with loss of appetite and weight loss for a duration of 6 to 8 weeks. Radiological examination revealed right adnexal lesion and nodular thickening along periampullary region. ERCP guided biopsy of the growth in periampullary region revealed moderately differentiated adenocarcinoma. She underwent pancreatico-duodenectomy with bilateral salpingo-oophorectomy. The histopathological examination revealed invasive carcinoma in both the ovaries, and moderately differentiated adenocarcinoma in periampullary and intra-ampullary region. As per the findings in previous studies, bilateral ovarian tumors of any size, or a unilateral tumor less than 10 cm likely represents metastatic disease rather than primary ovarian tumor. The rarity of co-presentation of pancreatic and adnexal mass makes the diagnosis tough however it is important to differentiate between primary ovarian mucinous cancers and ovarian metastasis from primaries in GIT for further treatment and follow up.

Whipple’s cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study

Effect of robotic versus open pancreaticoduodenectomy on postoperative length of hospital stay and complications for pancreatic head or periampullary tumours: a multicentre, open-label randomised controlled trial

PurposeTo develop a diagnostic model for distinguishing pancreatobiliary-type and intestinal-type periampullary adenocarcinomas using preoperative contrast-enhanced computed tomography (CT) findings combined with clinical characteristics.MethodsThis retrospective study included 140 patients with periampullary adenocarcinoma who underwent preoperative enhanced CT, including pancreaticobiliary (N = 100) and intestinal (N = 40) types. They were randomly assigned to the training or internal validation set in an 8:2 ratio. Additionally, an independent external cohort of 28 patients was enrolled. Various CT features of the periampullary region were evaluated and data from clinical and laboratory tests were collected. Five machine learning classifiers were developed to identify the histologic type of periampullary adenocarcinoma, including logistic regression, random forest, multi-layer perceptron, light gradient boosting, and eXtreme gradient boosting (XGBoost).ResultsAll machine learning classifiers except multi-layer perceptron used achieved good performance in distinguishing pancreatobiliary-type and intestinal-type adenocarcinomas, with the area under the curve (AUC) ranging from 0.75 to 0.98. The AUC values of the XGBoost classifier in the training set, internal validation set and external validation set are 0.98, 0.89 and 0.84 respectively. The enhancement degree of tumor, the growth pattern of tumor, and carbohydrate antigen 19–9 were the most important factors in the model.ConclusionMachine learning models combining CT with clinical features can serve as a noninvasive tool to differentiate the histological subtypes of periampullary adenocarcinoma, in particular using the XGBoost classifier.