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. 1989 Oct;210(4):544–556. doi: 10.1097/00000658-198910000-00015

Experience with 647 consecutive tumors of the duodenum, ampulla, head of the pancreas, and distal common bile duct.

F Michelassi 1, F Erroi 1, P J Dawson 1, A Pietrabissa 1, S Noda 1, M Handcock 1, G E Block 1
PMCID: PMC1357942  PMID: 2679459

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 carcinoid of the duodenum survived 5 years. No patient with 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 less than 0.001), histologic type (adenocarcinoma 2%, carcinoid and sarcoma 31%; p less than 0.0001), and site (ampullary and duodenal 21%, biliary and pancreatic 0.9%; p less than 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.(ABSTRACT TRUNCATED AT 400 WORDS)

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Selected References

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  1. Adkins R. B., Jr, Dunbar L. L., McKnight W. G., Farringer J. L., Jr An aggressive surgical approach to bile duct cancer. Am Surg. 1986 Mar;52(3):134–139. [PubMed] [Google Scholar]
  2. Alexander F., Rossi R. L., O'Bryan M., Khettry U., Braasch J. W., Watkins E., Jr Biliary carcinoma. A review of 109 cases. Am J Surg. 1984 Apr;147(4):503–509. doi: 10.1016/0002-9610(84)90013-8. [DOI] [PubMed] [Google Scholar]
  3. Alwmark A., Andersson A., Lasson A. Primary carcinoma of the duodenum. Ann Surg. 1980 Jan;191(1):13–18. doi: 10.1097/00000658-198001000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. BRINTNALL E. S. An evaluation of surgical treatment of carcinoma of the head of the pancreas. Cancer. 1952 Sep;5(5):908–910. doi: 10.1002/1097-0142(195209)5:5<908::aid-cncr2820050506>3.0.co;2-o. [DOI] [PubMed] [Google Scholar]
  5. BROADBENT T. R., KERMAN H. D. One hundred cases of carcinoma of the pancreas; a clinical and roentgenologic analysis. Gastroenterology. 1951 Feb;17(2):163–177. [PubMed] [Google Scholar]
  6. Balasegaram M. Carcinoma of the periampullary region: a review of a personal series of 87 patients. Br J Surg. 1976 Jul;63(7):532–537. doi: 10.1002/bjs.1800630710. [DOI] [PubMed] [Google Scholar]
  7. Bergstrand O., Ahlberg J., Ewerth S., Hellers G., Holmström B. A retrospective study of carcinoma of the pancreas with special reference to the results of surgical treatment. Acta Chir Scand Suppl. 1978;482:26–28. [PubMed] [Google Scholar]
  8. Björck S., Svensson J. O., Macpherson S., Edlund Y. Cancer of the head of the pancreas and choledochoduodenal junction: a clinical study of 88 Whipple resections. Acta Chir Scand. 1981;147(5):353–359. [PubMed] [Google Scholar]
  9. Bungay K., Dennistone S., Hunt P. S. Duodenal obstruction and carcinoma of the head of pancreas. Med J Aust. 1980 Aug 9;2(3):150–151. doi: 10.5694/j.1326-5377.1980.tb76948.x. [DOI] [PubMed] [Google Scholar]
  10. CLIFFTON E. E. Carcinoma of the pancreas; symptoms, signs, and results of treatment in one hundred twenty-two cases. AMA Arch Surg. 1952 Aug;65(2):290–306. [PubMed] [Google Scholar]
  11. Cohen J. R., Kuchta N., Geller N., Shires G. T., Dineen P. Pancreaticoduodenectomy. A 40-year experience. Ann Surg. 1982 May;195(5):608–617. doi: 10.1097/00000658-198205000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Collins J. J., Jr, Craighead J. E., Brooks J. R. Rationale for total pancreatectomy for carcinoma of the pancreatic head. N Engl J Med. 1966 Mar 17;274(11):599–602. doi: 10.1056/NEJM196603172741103. [DOI] [PubMed] [Google Scholar]
  13. Crane J. M., Gobbel W. G., Jr, Scott H. W., Jr Surgical experience with malignant tumors of the ampulla of vater and duodenum. Surg Gynecol Obstet. 1973 Dec;137(6):937–940. [PubMed] [Google Scholar]
  14. Dancer J. T., DuVal M. K., Jr Carcinoma of the head of the pancreas. A reappraisal and report of a five year cure. Am J Surg. 1965 Nov;110(5):704–708. doi: 10.1016/0002-9610(65)90110-8. [DOI] [PubMed] [Google Scholar]
  15. Deschamps G., Bourbeau D. Pancreatic carcinoma: surgical treatment. Can J Surg. 1984 Nov;27(6):559–560. [PubMed] [Google Scholar]
  16. Douglass H. O., Jr, Holyoke E. D. Pancreatic cancer. Initial treatment as the determinant of survival. JAMA. 1974 Aug 12;229(7):793–797. doi: 10.1001/jama.229.7.793. [DOI] [PubMed] [Google Scholar]
  17. Edis A. J., Kiernan P. D., Taylor W. F. Attempted curative resection of ductal carcinoma of the pancreas: review of Mayo Clinic experience, 1951-1975. Mayo Clin Proc. 1980 Sep;55(9):531–536. [PubMed] [Google Scholar]
  18. Elmslie R. G., Slavotinek A. H. Surgical objectives in unresected cancer of the head of the pancreas. Br J Surg. 1972 Jul;59(7):508–512. doi: 10.1002/bjs.1800590704. [DOI] [PubMed] [Google Scholar]
  19. Forrest J. F., Longmire W. P., Jr Carcinoma of the pancreas and periampullary region. Ann Surg. 1979 Feb;189(2):129–138. doi: 10.1097/00000658-197902000-00001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. GULLICK H. D. Carcinoma of the pancreas; a review and critical study of 100 cases. Medicine (Baltimore) 1959 Feb;38(1):47–84. doi: 10.1097/00005792-195902000-00003. [DOI] [PubMed] [Google Scholar]
  21. Grace P. A., Pitt H. A., Tompkins R. K., DenBesten L., Longmire W. P., Jr Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg. 1986 Jan;151(1):141–149. doi: 10.1016/0002-9610(86)90024-3. [DOI] [PubMed] [Google Scholar]
  22. Gudjonsson B. Cancer of the pancreas. 50 years of surgery. Cancer. 1987 Nov 1;60(9):2284–2303. doi: 10.1002/1097-0142(19871101)60:9<2284::aid-cncr2820600930>3.0.co;2-v. [DOI] [PubMed] [Google Scholar]
  23. Hayes D. H., Bolton J. S., Willis G. W., Bowen J. C. Carcinoma of the ampulla of Vater. Ann Surg. 1987 Nov;206(5):572–577. doi: 10.1097/00000658-198711000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Herter F. P., Cooperman A. M., Ahlborn T. N., Antinori C. Surgical experience with pancreatic and periampullary cancer. Ann Surg. 1982 Mar;195(3):274–281. doi: 10.1097/00000658-198203000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Hertzberg J. Pancreatico-duodenal resection and by-pass operation in patients with carcinoma of the head of the pancreas, ampulla, and distal end of the common duct. Acta Chir Scand. 1974;140(7):523–527. [PubMed] [Google Scholar]
  26. Hines L. H., Burns R. P. 10 years' experience treating pancreatic and periampullary cancer. Am Surg. 1976 Jun;42(6):441–447. [PubMed] [Google Scholar]
  27. Ihse I., Lilja P., Arnesjö B., Bengmark S. Total pancreatectomy for cancer. An appraisal of 65 cases. Ann Surg. 1977 Dec;186(6):675–680. doi: 10.1097/00000658-197712000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Isaksson G., Ihse I., Andrén-Sandberg A., Evander A., Löfgren B., Millbourn E. Local excision for ampullary carcinoma. An alternative treatment for patients unfit for pancreatectomy. Acta Chir Scand. 1982;148(2):163–165. [PubMed] [Google Scholar]
  29. Joesting D. R., Beart R. W., Jr, van Heerden J. A., Weiland L. H. Improving survival in adenocarcinoma of the duodenum. Am J Surg. 1981 Feb;141(2):228–231. doi: 10.1016/0002-9610(81)90163-x. [DOI] [PubMed] [Google Scholar]
  30. Jones B. A., Langer B., Taylor B. R., Girotti M. Periampullary tumors: which ones should be resected? Am J Surg. 1985 Jan;149(1):46–52. doi: 10.1016/s0002-9610(85)80008-8. [DOI] [PubMed] [Google Scholar]
  31. Kellum J. M., Clark J., Miller H. H. Pancreatoduodenectomy for resectable malignant periampullary tumors. Surg Gynecol Obstet. 1983 Oct;157(4):362–366. [PubMed] [Google Scholar]
  32. Langer J. C., Langer B., Taylor B. R., Zeldin R., Cummings B. Carcinoma of the extrahepatic bile ducts: results of an aggressive surgical approach. Surgery. 1985 Oct;98(4):752–759. [PubMed] [Google Scholar]
  33. Lees C. D., Zapolanski A., Cooperman A. M., Hermann R. E. Carcinoma of the bile ducts. Surg Gynecol Obstet. 1980 Aug;151(2):193–198. [PubMed] [Google Scholar]
  34. Levin B., ReMine W. H., Hermann R. E., Schein P. S., Cohn I., Jr Panel: cancer of the pancreas. Am J Surg. 1978 Feb;135(2):185–191. doi: 10.1016/0002-9610(78)90094-6. [DOI] [PubMed] [Google Scholar]
  35. MCDERMOTT W. V., Jr, BARTLETT M. K. Pancreaticoduodenal cancer. N Engl J Med. 1953 May 28;248(22):927–931. doi: 10.1056/NEJM195305282482202. [DOI] [PubMed] [Google Scholar]
  36. Matsuno S., Sato T. Surgical treatment for carcinoma of the pancreas. Experience in 272 patients. Am J Surg. 1986 Nov;152(5):499–504. doi: 10.1016/0002-9610(86)90214-x. [DOI] [PubMed] [Google Scholar]
  37. Morris P. J., Nardi G. L. Pancreaticoduodenal cancer. Experience from 1951 to 1960 with a look ahead and behind. Arch Surg. 1966 Jun;92(6):834–837. doi: 10.1001/archsurg.1966.01320240022005. [DOI] [PubMed] [Google Scholar]
  38. Nakase A., Matsumoto Y., Uchida K., Honjo I. Surgical treatment of cancer of the pancreas and the periampullary region: cumulative results in 57 institutions in Japan. Ann Surg. 1977 Jan;185(1):52–57. doi: 10.1097/00000658-197701000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Newman R. J., Pittam M. R. Local excision in the treatment of carcinoma of the ampulla of Vater. J R Coll Surg Edinb. 1982 May;27(3):154–157. [PubMed] [Google Scholar]
  40. Parkash O. On the statistical and clinical evaluation of carcinoma of the pancreas. A survey of 68 cases. Digestion. 1972;6(3):152–164. doi: 10.1159/000197234. [DOI] [PubMed] [Google Scholar]
  41. Parker G. A., Postlethwait R. W. The continuing problem of carcinoma of the pancreas. J Surg Oncol. 1985 Jan;28(1):36–38. doi: 10.1002/jso.2930280110. [DOI] [PubMed] [Google Scholar]
  42. Pliam M. B., ReMine W. H. Further evaluation of total pancreatectomy. Arch Surg. 1975 May;110(5):506–512. doi: 10.1001/archsurg.1975.01360110052010. [DOI] [PubMed] [Google Scholar]
  43. Pope N. A., Fish J. C. Palliative surgery for carcinoma of the pancreas. Am J Surg. 1971 Mar;121(3):271–272. doi: 10.1016/0002-9610(71)90203-0. [DOI] [PubMed] [Google Scholar]
  44. ROSS D. E. Cancer of the pancreas; a plea for total pancreatectomy. Am J Surg. 1954 Jan;87(1):20–33. doi: 10.1016/0002-9610(54)90038-0. [DOI] [PubMed] [Google Scholar]
  45. Rastogi H., Brown C. H. Carcinoma of the pancreas. A review of one hundred cases. Cleve Clin Q. 1967 Oct;34(4):243–263. doi: 10.3949/ccjm.34.4.243. [DOI] [PubMed] [Google Scholar]
  46. Richard L., Jr, Cohn I., Jr Cancer of the pancreas. Am Surg. 1969 Feb;35(2):95–103. [PubMed] [Google Scholar]
  47. Richards A. B., Sosin H. Cancer of the pancreas: the value of radical and palliative surgery. Ann Surg. 1973 Mar;177(3):325–331. doi: 10.1097/00000658-197303000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Rodgers C. M., Adams J. T., Schwartz S. I. Carcinoma of the extrahepatic bile ducts. Surgery. 1981 Oct;90(4):596–601. [PubMed] [Google Scholar]
  49. Rosenberg J. M., Welch J. P., Macaulay W. P. Cancer of the head of the pancreas: an institutional review with emphasis on surgical therapy. J Surg Oncol. 1985 Mar;28(3):217–221. doi: 10.1002/jso.2930280315. [DOI] [PubMed] [Google Scholar]
  50. STAFFORD E. S., TRIMBLE I. R., CLASSEN J. N. Results of treatment of carcinoma of pancreas. Ann Surg. 1954 Jun;139(6):800-3; discussion, 803-5. doi: 10.1097/00000658-195406000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Salmon P. A. Carcinoma of the pancreas and extrahepatic biliary system. Surgery. 1966 Sep;60(3):554–565. [PubMed] [Google Scholar]
  52. Sato T., Saitoh Y., Noto N., Matsuno S. Follow-up studies of radical resection for pancreaticoduodenal cancer. Ann Surg. 1977 Nov;186(5):581–588. doi: 10.1097/00000658-197711000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Shapiro T. M. Adenocarcinoma of the pancreas: a statistical analysis of biliary bypass vs Whipple resection in good risk patients. Ann Surg. 1975 Dec;182(6):715–721. doi: 10.1097/00000658-197512000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Stephenson L. W., Blackstone E. H., Aldrete J. A. Radical resection for periampullary carcinomas: results in 53 patients. Arch Surg. 1977 Mar;112(3):245–249. doi: 10.1001/archsurg.1977.01370030017003. [DOI] [PubMed] [Google Scholar]
  55. Takasan H., Kim C. I., Arii S., Takahashi S., Uozumi T., Tobe T., Honjo I. Clinicopathologic study of seventy patients with carcinoma of the biliary tract. Surg Gynecol Obstet. 1980 May;150(5):721–726. [PubMed] [Google Scholar]
  56. Tarazi R. Y., Hermann R. E., Vogt D. P., Hoerr S. O., Esselstyn C. B., Jr, Cooperman A. M., Steiger E., Grundfest S. Results of surgical treatment of periampullary tumors: a thirty-five-year experience. Surgery. 1986 Oct;100(4):716–723. [PubMed] [Google Scholar]
  57. Tompkins R. K., Thomas D., Wile A., Longmire W. P., Jr Prognostic factors in bile duct carcinoma: analysis of 96 cases. Ann Surg. 1981 Oct;194(4):447–457. doi: 10.1097/00000658-198110000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Tryka A. F., Brooks J. R. Histopathology in the evaluation of total pancreatectomy for ductal carcinoma. Ann Surg. 1979 Sep;190(3):373–381. doi: 10.1097/00000658-197909000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Ubhi C. S., Doran J. Palliation for carcinoma of head of pancreas. Ann R Coll Surg Engl. 1986 May;68(3):159–162. [PMC free article] [PubMed] [Google Scholar]
  60. Vijayanagar R., Tolins S. H. Evaluation of palliative operations for carcinoma of the head of the pancreas: a ten year study. Mt Sinai J Med. 1970 Mar-Apr;37(2):115–118. [PubMed] [Google Scholar]
  61. Webster D. J. Carcinoma of the pancreas and periampullary region: a clinical study in a district general hospital. Br J Surg. 1975 Feb;62(2):130–134. doi: 10.1002/bjs.1800620213. [DOI] [PubMed] [Google Scholar]
  62. Whipple A. O., Parsons W. B., Mullins C. R. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER. Ann Surg. 1935 Oct;102(4):763–779. doi: 10.1097/00000658-193510000-00023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Wilson S. M., Block G. E. Proceedings: Periampullary carcinoma. Arch Surg. 1974 Apr;108(4):539–544. doi: 10.1001/archsurg.1974.01350280141023. [DOI] [PubMed] [Google Scholar]
  64. Wise L., Pizzimbono C., Dehner L. P. Periampullary cancer. A clinicopathologic study of sixty-two patients. Am J Surg. 1976 Feb;131(2):141–148. doi: 10.1016/0002-9610(76)90087-8. [DOI] [PubMed] [Google Scholar]

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