The effect of pre-operative biliary drainage in resectable periampullary lesions: a systematic review and meta-analysis.

OBJECTIVE: The effect of a pre-operative biliary stent on complications after pancreaticoduodenectomy (PD) remains controversial. MATERIALS AND METHOD: We conducted a meta-analysis according to the preferred reporting items for systematic reviews and meta-analyses guidelines, and PubMed, Web of Science Knowledge, and Ovid's databases were searched by the end of February 2023. 35 retrospective studies and 2 randomized controlled trials with a total of 12641 patients were included. RESULTS: The overall complication rate of the pre-operative biliary drainage (PBD) group was significantly higher than the no-PBD group (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.22-1.74; p < 0.0001), the incidence of post-operative delayed gastric emptying was increased in patients with PBD compared those with early surgery (OR 1.21, 95% CI: 1.02-1.43; p = 0.03), and there was a significant increase in post-operative wound infections in patients receiving PBD with an OR of 2.2 (95% CI: 1.76-2.76; p < 0.00001). CONCLUSIONS: PBD has no beneficial effect on post-operative outcomes. The increase in post-operative overall complications and wound infections urges the exact indications for PBD and against routine pre-operative biliary decompression, especially for patients with total bilirubin < 250 umol/L waiting for PD.

OBJETIVO: El efecto de una endoprótesis biliar pre-operatoria sobre las complicaciones después de la pancreaticoduodenectomía sigue siendo controvertido. MATERIALES Y MÉTODO: Se llevó a cabo un metaanálisis siguiendo las directrices PRISMA y se realizaron búsquedas en PubMed, Web of Science Knowledge y la base de datos de Ovid hasta finales de febrero de 2023. Se incluyeron 35 estudios retrospectivos y 2 ensayos controlados aleatorizados, con un total de 12,641 pacientes. RESULTADOS: La tasa global de complicaciones del grupo drenaje biliar pre-operatorio (PBD) fue significativamente mayor que la del grupo no-PBD (odds ratio [OR]: 1.46; intervalo de confianza del 95% [IC 95%]: 1.22-1.74; p < 0.0001), la incidencia de vaciado gástrico retardado posoperatorio fue mayor en los pacientes con PBD en comparación con los de cirugía precoz (OR: 1.21; IC95%: 1.02-1.43; p = 0.03), y hubo un aumento significativo de las infecciones posoperatorias de la herida en los pacientes que recibieron PBD (OR: 2.2; IC 95%: 1.76-2.76; p < 0.00001). CONCLUSIONES: El drenaje biliar pre-operatorio no tiene ningún efecto beneficioso sobre el resultado posoperatorio. El aumento de las complicaciones posoperatorias globales y de las infecciones de la herida urge a precisar las indicaciones de PBD y a desaconsejar la descompresión biliar pre-operatoria sistemática, en especial en pacientes con bilirrubina total inferior a 250 µmol/l en espera de pancreaticoduodenectomía.

Comparison of the two histological subtypes of ampullary adenocarcinoma: a retrospective study.

OBJECTIVES: This study aimed to compare the intestinal and pancreatobiliary subtypes of ampullary adenocarcinoma in a large patient group due to limited data on survival and risk factors. METHODS: A retrospective analysis of the clinical and pathological findings and the survival of 184 patients with ampullary adenocarcinoma who underwent curative operation between 2007 and 2018 was performed. RESULTS: Pancreatobiliary subtype had a higher prevalence of jaundice before operation than the intestinal subtype (p < 0.05). Pancreatobiliary subtype had a larger tumor size (> 2 mm) (p < 0.01) and poorer differentiation (p < 0.05) than the intestinal subtype. Perineural invasion more frequently occurred in pancreatobiliary subtype than the intestinal subtype (p < 0.01) and pancreatobiliary subtype had a higher prevalence of positive dissected lymph nodes (p < 0.05) with an advanced disease stage (p < 0.01) than the intestinal subtype. Patients of the pancreatobiliary subtype had poorer disease-free and overall survival than patients of the intestinal subtype. No survival benefit of adjuvant chemotherapy was found in either patients of the intestinal subtype or pancreatobiliary subtype. No significant difference was found in any subtypes regarding the recurrent regions. CONCLUSIONS: Pancreatobiliary subtype exhibited a higher recurrence rate and a poorer overall survival rate with more unfavorable pathological characteristics than the intestinal subtype.

OBJETIVOS: Los datos sobre la supervivencia y los factores de riesgo del adenocarcinoma ampular son limitados debido a su rareza. Este estudio buscó comparar el subtipo intestinal y el subtipo pancreático-biliar en pacientes con adenocarcinoma ampular. MÉTODOS: Análisis retrospectivo de hallazgos clínicos y patológicos y la supervivencia de 184 pacientes con adenocarcinoma ampular tratados entre 2007 y 2018. RESULTADOS: El subtipo pancreático-biliar tuvo una mayor prevalencia de ictericia antes de la operación y un tamaño de tumor mayor, y una peor diferenciación, que el subtipo intestinal. La invasión perineural fue más frecuente en el subtipo pancreático-biliar, con una mayor prevalencia de linfonodos disecados positivos y un estadio avanzado de la enfermedad. Los pacientes del subtipo pancreático-biliar tuvieron una supervivencia libre de enfermedad y una supervivencia general peores que los pacientes del subtipo intestinal. No se encontró ningún beneficio de la quimioterapia adyuvante en pacientes del subtipo intestinal o pancreático-biliar. No hubo diferencia significativa en las regiones recurrentes. CONCLUSIÓN: El subtipo pancreático-biliar mostró una tasa de recurrencia y una tasa de supervivencia general peores, con características patológicas más desfavorables que el subtipo intestinal.

Prognostic value of nodal staging classification and number of examined lymph nodes among patients with ampullary cancer.

BACKGROUND: Metastatic disease in the regional lymph nodes (LNs) is a strong indicator of worse outcomes among patients after curative-intent resection of ampullary cancer (AC). This study aimed to ascertain the threshold number of examined LNs (ELNs) for AC to compare the prognosis accuracy of various nodal classification schemes relative to long-term prognosis. METHODS: Patients who underwent pancreatoduodenectomy (PD) for AC (2004-2019) were identified using the National Cancer Database. Locally weighted regression scatter plot smoothing (LOWESS) curves were used to ascertain the optimal cut point for ELNs. The accuracy of the American Joint Committee on Cancer N classification, LN ratio, and log odds transformation (LODDS) ratio to stratify patients relative to survival was examined. RESULTS: Among 8127 patients with AC, 67% were male with a median age of 67 years (IQR, 59-74). Tumors were most frequently classified as T3 (34.9%), followed by T2 (30.6%); T1 (12.9%) and T4 (17.6%) were less common. LN metastasis was identified in 4606 patients (56.7%). Among patients with nodal disease, 37.0% and 19.7% had N1 and N2 disease, respectively. The LOWESS curves identified an inflection cutoff point in the hazard of survival at 20 ELNs. The survival benefit of 20 ELNs was more pronounced among patients without LN metastasis vs patients with N1 disease (median overall survival [OS]: 54.1 months [IQR, 45.9-62.1] in ≥20 ELNs vs 39.0 months [IQR, 35.8-42.2] in <20 ELNs; P < .001) or N2 disease (median OS: 22.5 months [IQR, 18.9-26.2] in ≥20 ELNs vs 25.4 months [IQR, 23.3-27.6] in <20 ELNs; P < .001). When comparing the 4 different N classification schemes, the LODDS classification scheme yielded the highest predictive ability. CONCLUSIONS: Evaluation of a minimum of 20 LNs was needed to stratify patients with AC relative to the prognosis and to minimize stage migration. The LODDS nodal classification scheme had the highest prognostic accuracy to differentiate survival among patients after PD for AC.

[Primary neuroendocrine tumor of the common bile duct] / Tumor neuroendocrino primario del conducto hepático común.

Primary neuroendocrine tumors (NETs) of the bile duct are extremely rare and represent only 0.2-2% of all gastrointestinal NETs. Within the biliary system, the main bile duct is the most affected site. A 28-year-old man with a 6-month history of intermittent jaundice, pruritus, and choluria. MRCP, PET-CT and endoscopic ultrasound were performed. A well-differentiated neuroendocrine neoplasia was diagnosed. Complete resection of the main bile duct was performed with lymphadenectomy of the hepatic pedicle with Roux-en-Y hepaticojejunostomy, without complications. The patient had an adequate evolution and nowadays he's disease-free. Primary neuroendocrine tumors of the bile duct are extremely rare. They may present clinically and radiologically similar to perihilar cholangiocarcinoma, which makes preoperative diagnosis difficult. Radical resection is indicated. Usually, they are well differentiated tumors, being the Ki-67 labeling index a reliable prognostic marker.

Los tumores neuroendocrinos (TNE) primarios de la vía biliar son extremadamente raros y representan sólo el 0.2-2% de todos los TNE gastrointestinales. Dentro del sistema biliar, la vía biliar principal es el sitio más afectado. Hombre de 28 años con cuadro de 6 meses de evolución caracterizado por ictericia intermitente, prurito y coluria. Se realizó colangiopancreatoresonancia magnética nuclear, PET-TC y ultrasonido endoscópico que concluyeron neoplasia neuroendocrina bien diferenciada. Se realizó resección completa de la vía biliar principal con linfadenectomía del pedículo hepático con hepaticoyeyunoanastomosis en Y de Roux, sin complicaciones. El paciente cursó adecuada evolución y se encuentra libre de enfermedad. Los tumores neuroendocrinos primarios de la vía biliar son extremadamente raros, presentándose clínica y radiológicamente como lesiones similares al colangiocarcinoma perihiliar lo que dificulta el diagnóstico preoperatorio. Está indicado su tratamiento quirúrgico radical. Suelen ser bien diferenciados, siendo el antígeno Ki-67 un marcador pronóstico confiable.

[Acquired paraneoplastic hemophilia secondary to Vater's ampulla adenocarcinoma]. / Hemofilia paraneoplásica adquirida secundaria a adenocarcinoma de la ampolla de Vater.

Acquired hemophilia A is an unusual bleeding disorder of autoimmune origin resulting in the formation of autoantibodies directed against coagulation factor VIII. These autoantibodies can act by partially or completely neutralizing the activation or function of the factor, or they can also accelerate its elimination from the circulation. The global incidence of the disease is 1.5 cases per million inhabitants per year. In nearly 50% of cases, an underlying disease that is presumed responsible to produce autoantibodies can be detected. We report a case with acquired hemophilia A, in a patient with Vater's ampulla adenocarcinoma.

La hemofilia adquirida A es un desorden hemorrágico inusual de origen autoinmune que resulta en la formación de autoanticuerpos dirigidos contra el factor VIII de la coagulación. Estos autoanticuerpos pueden actuar neutralizando parcial o completamente la activación o función del factor, o también pueden acelerar su eliminación de la circulación. La incidencia mundial de la enfermedad es de 1.5 casos por millón de habitantes por año. En cerca del 50% de los pacientes se puede detectar una enfermedad subyacente que se presume responsable de la producción de los autoanticuerpos. Se presenta el caso de un varón con hemofilia adquirida A, en contexto de adenocarcinoma de la ampolla de Vater.

Hemofilia paraneoplásica adquirida secundaria a adenocarcinoma de la ampolla de Vater / Acquired paraneoplastic hemophilia secondary to Vater's ampulla adenocarcinoma

Resumen La hemofilia adquirida A es un desorden hemorrágico inusual de origen autoinmune que resulta en la formación de autoanticuerpos dirigidos contra el factor VIII de la coagulación. Estos autoanticuer pos pueden actuar neutralizando parcial o completamente la activación o función del factor, o también pueden acelerar su eliminación de la circulación. La incidencia mundial de la enfermedad es de 1.5 casos por millón de habitantes por año. En cerca del 50% de los pacientes se puede detectar una enfermedad subyacente que se presume responsable de la producción de los autoanticuerpos. Se presenta el caso de un varón con hemofilia adquirida A, en contexto de adenocarcinoma de la ampolla de Vater.

Abstract Acquired hemophilia A is an unusual bleeding disorder of autoimmune origin resulting in the formation of autoantibodies directed against coagulation factor VIII. These autoantibodies can act by partially or completely neutralizing the activation or function of the factor, or they can also accelerate its elimination from the circulation. The global incidence of the disease is 1.5 cases per million inhabitants per year. In nearly 50% of cases, an underlying disease that is presumed responsible to produce autoantibodies can be detected. We report a case with acquired hemophilia A, in a patient with Vater's ampulla adenocarcinoma.

Colangiocarcinoma, diagnóstico, tratamiento y evolución clínica. Presentación de un caso con sobrevida 5 años / Cholangiocarcinoma: diagnosis, treatment and clinical evolution. Presentation of a case with five-year survival

RESUMEN El colangiocarcinoma es un tumor maligno originado en el epitelio de los conductos biliares intra o extrahepáticos. En el cuadro clínico destacan el dolor en hipocondrio derecho, ictericia y baja de peso. Actualmente, el diagnóstico se ha facilitado por la disponibilidad de variados procedimientos imagenológicos y endoscópicos. Se presentó un caso al que se le realizó el diagnóstico de este tipo de tumor. Se sometió a tratamiento endoscópico, quirúrgico y oncológico con Gemcitabina, Cisplatino y Oxaliplatino. Fue seguido por equipo multidisciplinario y evolucionó con sobrevida de 5 años (AU).

ABSTRACT Cholangiocarcinoma is a malignant tumor originated in the epithelium of the intra or extra hepatic biliary ducts. Pain in the right hypochondrium, jaundice and low weight are the main clinical features. Currently, the diagnosis has been facilitated by the availability of different imaging and endoscopic procedures. The authors presented a case diagnosed with this kind of tumor. The patient underwent surgical, endoscopic and oncologic treatment with gemcitabine, cisplatine and oxaliplatine. He was followed up by a multidisciplinary team and evolved with five-year survival (AU).

Prognostic Factors of Long-term Survival Following Radical Resection for Ampullary Carcinoma.

BACKGROUND: The incidence of adenocarcinoma of the ampulla of Vater has been increasing over the past years. Nevertheless, it is still a rare disease and the prognostic factors predicting long-term survival are not sufficiently clarified. This study aims to evaluate the association between histopathological characteristics and long-term survival of patients with ampullary cancer after curative resection, as well as the efficiency of immunohistochemical expression of CK7, CK20, and CDX2 to distinguish the histopathological (intestinal or pancreaticobiliary) patterns. METHODS: Demographic, histopathological data, pTNM stage, and immunohistochemical expression patterns were collected from 65 patients with adenocarcinoma of the ampulla of Vater. Five and 10-year overall and disease-free survival rates after curative resection were determined. RESULTS: Of the 65 patients with ampullary carcinoma, 47 (72%) underwent radical resection. The 5- and 10-year overall survival rate was 46% and 37%, respectively. Our results demonstrate that the main prognostic factors were the presence and number of lymph node metastases, lymph node ratio (LNR), differentiation grade, and lymphovascular invasion. After multivariate analysis, only lymph node ratio ≥ 20% remained an independent prognostic factor of survival (HR: 2.63 95% CI: 1.05-6.61; p = 0.039). CONCLUSION: Here, we demonstrated more evidence that the lymph node metastases are associated with poor prognosis in ampullary carcinoma. Particularly, the relation between the number of metastatic lymph nodes and the number of harvested lymph node (LNR) should be considered a major prognostic factor.

ENDOSCOPIC PAPILLECTOMY FOR EARLY AMPULLARY NEOPLASTIC LESIONS - A CASE SERIES ANALYSIS.

BACKGROUND: Endoscopic papillectomy has been conceived as a less invasive therapeutic option for treatment of early neoplastic lesions located at the major duodenal papilla. OBJECTIVE: Evaluating patients with early ampullary lesions who underwent curative intent endoscopic papillectomy related to technical success (histopathological tumor margin assessment) and safety (adverse event rate). METHODS: A retrospective study including consecutive patients who underwent curative intent endoscopic papillectomy for demographic, histopathological and pre-/post-procedural clinical assessment. Endpoints were technical success (histopathological residual tumor assessment) and adverse events rates. RESULTS: A total of 21 medical records patients with a female predominance (13 cases, 61.9%) were included. The tumor was incidental in 8 (38%) cases. Negative residual tumor resection margin rate was 72% (15 cases); three of these cases confirmed high-grade dysplasia in the resected specimen, and six cases were invasive neoplasia. Tumoral recurrence was seen in two cases, and median follow-up time was 12 months, with a 23% loss rate (five patients). Six (28.5%) patients had adverse events, all of them early (bleeding and pancreatitis); none of them required surgical intervention and there was no mortality. CONCLUSION: Endoscopic papillectomy allowed for technical successful procedure with complete removal of ampullary neoplastic lesions in the majority of cases with acceptable adverse event rates. Recurrence rate should be carefully assessed in further studies. There was a recent increase in the number of procedures. There was also a low correlation between pre- and post-histopathological assessment regarding the presence of invasive carcinoma and adenoma with high grade dysplasia, with a predominance of superficial neoplastic adenomatous lesions.

Emprego da papilectomia endoscópica para tratamento de tumores precoces da papila duodenal maior - série de casos / Endoscopic papillectomy for early ampullary neoplastic lesions - a case series analysis

ABSTRACT BACKGROUND: Endoscopic papillectomy has been conceived as a less invasive therapeutic option for treatment of early neoplastic lesions located at the major duodenal papilla. OBJECTIVE: Evaluating patients with early ampullary lesions who underwent curative intent endoscopic papillectomy related to technical success (histopathological tumor margin assessment) and safety (adverse event rate). METHODS: A retrospective study including consecutive patients who underwent curative intent endoscopic papillectomy for demographic, histopathological and pre-/post-procedural clinical assessment. Endpoints were technical success (histopathological residual tumor assessment) and adverse events rates. RESULTS: A total of 21 medical records patients with a female predominance (13 cases, 61.9%) were included. The tumor was incidental in 8 (38%) cases. Negative residual tumor resection margin rate was 72% (15 cases); three of these cases confirmed high-grade dysplasia in the resected specimen, and six cases were invasive neoplasia. Tumoral recurrence was seen in two cases, and median follow-up time was 12 months, with a 23% loss rate (five patients). Six (28.5%) patients had adverse events, all of them early (bleeding and pancreatitis); none of them required surgical intervention and there was no mortality. CONCLUSION: Endoscopic papillectomy allowed for technical successful procedure with complete removal of ampullary neoplastic lesions in the majority of cases with acceptable adverse event rates. Recurrence rate should be carefully assessed in further studies. There was a recent increase in the number of procedures. There was also a low correlation between pre- and post-histopathological assessment regarding the presence of invasive carcinoma and adenoma with high grade dysplasia, with a predominance of superficial neoplastic adenomatous lesions.

RESUMO CONTEXTO: A papilectomia endoscópica tem sido a opção terapêutica menos invasiva no tratamento de tumores precoces que acometem a papila duodenal maior. OBJETIVO: Avaliar pacientes com tumores ampulares precoces submetidos a papilectomia endoscópica com finalidade curativa, com relação ao sucesso técnico (avaliação histopatológica da margem tumoral) e sua segurança (taxa de eventos adversos [EAs]). MÉTODOS: Foram avaliados retrospectivamente dados demográficos, exame histopatológico e evolução clínica pré e pós-procedimento de pacientes consecutivos submetidos a papilectomia endoscópica. Os desfechos avaliados foram o sucesso técnico (avaliação histopatológica de tumor residual) e taxa de EAs. RESULTADOS: Um total de 21 prontuários de pacientes com predominância feminina (13 casos, 61,9%) foi incluído no estudo. O diagnóstico tumoral foi incidental em 8 (38%) casos. A taxa de margem de ressecção negativa foi 72% (15 casos); três destas lesões confirmaram displasia de alto grau (DAG) no espécime ressecado e seis casos de neoplasia invasora. Houve recorrência tumoral em dois casos e a mediana de seguimento foi de 12 meses, com 23% de taxa de perda de seguimento (cinco casos). Seis (28,5%) pacientes apresentaram EAs, todos precoces (hemorragia e pancreatite aguda); nenhum destes necessitou de intervenção cirúrgica e não houve mortalidade. CONCLUSÃO: A papilectomia endoscópica permitiu sucesso técnico, com a completa remoção de lesões neoplásicas ampulares na maioria dos casos com taxa de EAs aceitáveis. A taxa de recorrência tumoral deve ser cuidadosamente avaliada em estudos futuros. Houve um aumento recente do número de procedimentos realizados. Também houve baixa correlação entre o diagnóstico histológico pré e pós-procedimento para a presença de adenocarcinoma invasor e adenoma com DAG, com predomínio de lesões adenomatosas superficiais.

Cap-assisted endoscopy increases ampulla of Vater visualization in high-risk patients.

BACKGROUND: Periampullary adenocarcinoma is a major clinical problem in high-risk patients including FAP population. A recent modification for visualizing the ampulla of Vater (AV) involves attaching a cap to the tip of the forward-viewing endoscope. Our aim was to compare the rates of complete visualization of AV using this cap-assisted endoscopy (CAE) approach to standard forward-viewing endoscopy (FVE). We also determined: (i) the rates of complications and additional sedation; (ii) the mean time required for duodenal examination; and (iii) the reproducibility among endoscopists performing this procedure. METHODS: We performed esophagogastroduodenoscopy for AV visualization in 102 > 18 years old using FVE followed by CAE. Video recordings were blinded and randomly selected for independent expert endoscopic evaluation. RESULTS: The complete visualization rate for AV was higher in CAE (97.0%) compared to FVE (51.0%) (p <  0.001). The additional doses of fentanyl, midazolam, and propofol required for CAE were 0.05, 1.9 and 36.3 mg. in 0.9, 24.5, and 77.5% patients, respectively. The mean time of duodenal examination for AV visualization was lower on CAE compared to FVE (1.41 vs. 1.95 min, p <  0.001). Scopolamine was used in 34 FVE and 24 CAE, with no association to AV complete visualization rates (p = 0.30 and p = 0.14). Three more ampullary adenomas were detected using CAE compared to FVE. Cap displacement occurred in one patient, and there was no observed adverse effect of the additional sedatives used. Kappa values for agreement between endoscopists ranged from 0.60 to 0.85. CONCLUSIONS: CAE is feasible, reproducible and safe, with a higher success rate for complete visualization compared to FVE. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02867826 , 16 August 2016.

Laparoscopic pancreatoduodenectoy.

BACKGROUND: Pancreatoduodenectomy or Whipple's operation, is the elective surgical procedure to treat different periampullary diseases. Through the years this surgery has been doing open, but in the lasts decades thanks to the improve technology and trained surgeons, today is feasible doing it laparoscopic with good results. OBJECTIVE: To present the initial experience and results in totally laparoscopic pancreatoduodenectomy in Hospital Regional ISSSTE Puebla, reporting the second number of cases in México. METHOD: Since July 2014-July 2018, 8 patients has been operated by totally laparoscopic pancreatoduodenectomy, 7 in Hospital Regional ISSSTE Puebla and 1 in a private Hospital. RESULTS: Evaluating all the patients, not one had mortality during operation, no morbidity or immediate reoperation, so the results are favourable. CONCLUSION: Laparoscopic pancreatoduodenectomy is a very complex procedure but feasible, and good results depends on various factors, like the appropriate patient selection.

ANTECEDENTES: La pancreatoduodenectomía o cirugía de Whipple es el procedimiento de elección en el tratamiento de las enfermedades periampulares. A través de los años se ha realizado de manera abierta, y actualmente, gracias a la mejora de los recursos humanos y tecnológicos, se realiza este procedimiento por mínima invasión con buenos resultados. OBJETIVO: Presentar la experiencia inicial en la pancreatoduodenectomía totalmente laparoscópica en el Hospital de Alta Especialidad del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) de Puebla, dando a conocer la segunda serie de casos reportada en México. MÉTODO: De julio de 2014 a julio de 2018 se han realizado ocho pancreatoduodenectomías totalmente laparoscópicas, siete en el hospital de alta especialidad ISSSTE Puebla y una en un hospital privado. RESULTADOS: En todos los pacientes intervenidos los resultados son favorables, sin mortalidad transoperatoria y sin presentar complicaciones graves ni reintervención. CONCLUSIÓN: La pancreatoduodenectomía laparoscópica es un procedimiento de alta complejidad que, teniendo una adecuada selección de pacientes y un manejo multidisciplinario, se puede llevar a cabo con excelentes resultados.

Analysis of risk factors associated with acute pancreatitis after endoscopic papillectomy.

Acute pancreatitis (AP) is a common adverse event (AE) of endoscopic papillectomy (EP). Prophylactic plastic pancreatic stent (PPS) placement appears to prevent AP. We evaluated factors associated with post-EP AP by a retrospective analysis of patients with tumors of the duodenal papilla who underwent EP from January 2008 to November 2016 at 2 tertiary care centers. Clinical, laboratory, endoscopic ultrasound parameters, and PPS placement were evaluated. Seventy-two patients underwent EP (37 men), with mean age of 60.3 (31-88) years. Mean main pancreatic duct (MPD) diameter was 0.44 (0.18-1.8) cm. Mean tumor size was 1.8 (0.5-9.6) cm. Tumors were staged as uT1N0, uT2N0, and uT1N1 in 87.5%, 11.1%, and 1.4%. Thirty-eight AEs occurred in 33 (45.8%) patients, with no mortality. Total bilirubin, tumor size, MPD diameter, and PPS placement had odds ratios (ORs) of 0.82, 0.14, 0.00, and 6.43 for AP. Multivariate analysis (PPS placement × MPD diameter) showed ORs of 4.62 (95%CI, 1.03-21.32; p = 0.049) and 0.000 (95%CI, 0.00-0.74; p = 0.042) for AP. In conclusion, patients with jaundice, large tumors, and dilated MPD seem less likely to have post-EP AP. PPS placement was associated with a higher risk of AP, which may question its use.

Adjuvant therapy for true ampullary cancer: a systematic review.

BACKGROUND: Given the lack of evidence on the best adjuvant approach, this review closely examines optimal adjuvant management for resected true ampullary cancer and its histological subtypes. MATERIALS AND METHODS: A comprehensive literature search of PubMed was performed to identify studies on resected true ampullary cancers, published between January 2010 and December 2018. Data including the use of radiation, chemotherapy or chemoradiation and the outcomes were extracted. RESULTS: A total of 116 records were identified, of which 65 screened were selected. Finally, nine studies were included. Only two of the studies reported separately the outcomes of pancreatobiliary and intestinal subtypes. Patients in the selected studies were treated with a pancreaticoduodenectomy with negative margins. Patients treated with adjuvant therapy were more likely to be pT3-4 and have positive nodes; median survival ranged from 30 to 47 months. A significant benefit for adjuvant treatment was observed in four of the studies, restricted to patients at stage IIB or higher. Likewise, patients with positive nodes may have a longer median survival with adjuvant chemoradiation compared to observation. CONCLUSIONS: The present review suggests a benefit for adjuvant treatment for patients with locally advanced tumors. Randomized trials are needed to ascertain the topic, as well as studies reporting toxicity and quality of life of resected true ampullary cancer patients.

Ictericia obstructiva por neuroma de amputación de vía biliar: Reporte de caso / Obstructive ictericia by neuroma of amputation of via biliar: Case report

Los neuromas del conducto biliar se desarrollan a partir de las fibras nerviosas simpáticas y parasimpáticas que envuelven la pared de la vía biliar. Mujer de 44 años de edad con antecedente de colecistectomía convencional seis meses previos al ingreso acude a emergencia por ictericia obstructiva de 15 días de evolución. En los estudios de imagen impresiona la presencia de una masa a nivel de las vías biliares considerándose el diagnostico de una neoplasia maligna. Por los antecedentes, ausencia de marcadores tumorales se decide realizar una biopsia percutánea sin resultados concluyente, realizándose posteriormente una intervención quirúrgica con estudio anatomo-patológico compatible con neuroma de amputación de vía biliar. El neuroma de amputación a nivel de la vía biliar es un tumor infrecuente. Puede manifestarse clínicamente como una ictericia obstructiva y suele simular a un tumor maligno de las vías biliares. El manejo quirúrgico es el tratamiento definitivo.

Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.

Carcinosarcoma of the ampulla of Vater.

Carcinosarcomas, are very rare tumors in gastrointestinal tract, and at the ampulla of Vater location, are extremely uncommon. They are also called spindle cell carcinomas or sarcomatoid carcinomas. These tumors have an aggressive clinical course with frequent metastasis. We report the case of a male patient of 64 y.o with anemia and jaundice, and a diagnosis of carcinosarcoma of the ampulla of Vater.

Ampulary tumors: presurgical staging by endoscopic ultrasonography. Diagnostic test study.

OBJECTIVE: To analyze the accuracy of endoscopic ultrasound (EUS) in the evaluation of ampullary tumors compared to histopathology (HP) staging. METHODS: A retrospective diagnostic test study. Patients with ampullary tumors staged by EUS and postpancreatoduodenectomy HP attended during 2012-2018 at tertiary level hospital. RESULTS: 14 patients with adenocarcinoma where included. Tumor size measured by EUS showed an adequate correlation (R = 0.65; p= 0.01) with HP. The accuracy in the evaluation of duodenal wall, pancreatic, and biliary duct invasion was 78.5, 78.5 and 57.1%, respectively. By HP, there were three T1 (21.4%), two T2 (14.2%) and nine T3 (64.2%). The accuracy of T and N staging by EUS was 71.4% (kappa = 0.50) and 50% (kappa = -0.04) respectively. There were more staging errors in patients with biliary stent. CONCLUSION: EUS was useful in estimating tumor size, duodenal wall and pancreatic invasion. Limitation was found in the evaluation of biliary duct invasion, as well as overestimation of T stage and underestimation of N stage. It is necessary an increased effort in ultrasonography training. We suggest EUS testing before biliary stenting.

OBJETIVO: Comparar el ultrasonido endoscópico (USE) en la valoración de los tumores ampulares primarios (TAp) con referencia al estudio histopatológico (HP). MÉTODO: Estudio retrospectivo prolectivo de pruebas diagnósticas en pacientes con TAp estadificados por USE y pancreatoduodenectomía con estudio HP, atendidos de 2012 a 2018 en un hospital de tercer nivel de atención. RESULTADOS: Fueron incluidos14 pacientes con adenocarcinoma. El tamaño del tumor medido por USE mostró una adecuada correlación (R = 0.65; p = 0.01) con el HP. La exactitud en la determinación de la invasión a la pared duodenal, el páncreas y el conducto biliar fue del 78.5, el 78.5 y el 57.1%, respectivamente. Por HP hubo tres T1 (21.4%), dos T2 (14.2%) y nueve T3 (64.2%). La exactitud del estadiaje T y N por USE fue del 71.4% (kappa = 0.50) y del 50% (kappa = −0.04), respectivamente. Los errores en la estadificación fueron más frecuentes en los pacientes con prótesis biliar. CONCLUSIÓN: El USE mostró utilidad en la determinación del tamaño tumoral y de la invasión al duodeno y al páncreas, y más limitada en la determinación de la invasión al conducto biliar por presencia de prótesis. Se observa una sobreestimación del estadiaje T y una subestimación del N. Es necesario mayor capacitación y sugerimos realizarse antes de colocar una prótesis biliar.