Experience with 647 Consecutive Tumors of the Duodenum, Ampulla, Head of the Pancreas, and Distal Common Bile Duct

Abstract

Between 1946 and 1987, 647 patients with periampullary tumors were diagnosed at the University of Chicago Medical Center. These included 549 tumors located in the head of the pancreas, 40 in the distal common bile duct, 29 in the duodenum, and 29 at the ampulla of Vater. Ninety-eight per cent of all tumors were adenocarcinoma, with 93% of the remaining being duodenal carcinoid or sarcoma. Operability rate ranged from 81% to 97%, according to the tumor location and histologic type. A combination of laparotomy, biopsy, and bypass was performed in 433 patients and only one survived 5 years (0.2%). Resectability rate ranged from 16.5% for pancreatic adenocarcinoma to 89.3% for ampullary tumors. Of the 133 resections, 80 were pancreatoduodenectomies, 29 total pancreatectomies, 7 duodenectomies, 2 gastrectomies, 8 common bile duct resections, and 7 local excisions. Overall 19% of patients who underwent radical resection died in the immediate postoperative period, although mortality has decreased to 5% since 1981. Mortality was 20% after a standard pancreatoduodenectomy and 24.1% after a total pancreatectomy. Five-year actuarial survival rates, including perioperative deaths, were 8.8%, 20%, and 32% for pancreatic, duodenal, and ampullary adenocarcinoma, respectively. One half of patients with sarcoma and two thirds with carinoid of the duodenum survived 5 years. No patient wtih distal common bile duct adenocarcinoma achieved a 5-year survival rate. Multivariate analysis on all patients operated on (n = 566) revealed that the 5-year survival rate was significantly related to intent of operation (palliative 0.2%, curative 12%; p = 0.001), histologic type (adenocarcinoma 2%, carcinoid and sarcoma 31%; p < 0.0001), and site (ampullary and duodenal 21%, biliary and pancreatic 0.9%; p < 0.001). A second multivariate analysis, evaluating only those patients with adenocarcinoma who survived the perioperative period of the radical resection (n = 97) analyzed the influence of tumor size and differentiation, lymphatic, capillary, and perineural microinvasion, lymph node status, and type of procedure (pancreatoduodenectomy vs. total pancreatectomy) on 5-year survival. None of these additional variables was significantly associated with long-term survival rates. In addition we evaluated the presence of local or distant recurrence after resection by analyzing the findings from all autopsies performed on these patients (n = 49): 29.4% of patients died with local recurrence alone, 23.5% with distant recurrence alone, and 47.1% had both local and distant recurrences. The occurrence of multicentricity in pancreatic adenocarcinoma was investigated in 36 patients in whom the entire gland was examined histologically. Multicentricity was noted in only one instance (2.8%). These results suggest that intent of operation, tumor side, and histologic type determine the outcome of patients with periampullary tumors. Although a curative resection offers the best chance for long-term survival, our results emphasize the limitation of our staging and selection. Multicentricity occurs rarely and total pancreatectomy does not acieve a lower perioperative mortality or better survival rates than standard pancreatoduodenectomy, indicating that the latter is the resection of choice unless multicentricity is obvious at exploration.