R1 Endoscopic papillectomy for adenocarcinoma: is complementary pancreatoduodenectomy unavoidable?

Research on the oncological outcomes of complementary pancreatoduodenectomy (PD) following incomplete (R1) endoscopic papillectomy (EP) for early-stage ampullary adenocarcinoma (AA) is limited, despite the increasing use of endoscopic approaches and the risks associated with PD. This study aimed to assess short- and long-term outcomes in patients undergoing complementary PD after EP R1 for AA.

Between January 2010 and December 2022, four patient groups were compared: patients with complete endoscopic resection (EP R0), those with R1 margins after EP closely followed up without complementary surgery (EP R1), those who underwent complementary PD after R1 EP (EP + PD), and those who underwent upfront PD (uPD). The primary endpoint was the difference in survival rates (overall [OS] and disease-free [DFS]) between the EP R1 and EP + PD groups and morbidity and mortality rate comparison between the EP + PD and uPD groups.

In the EP cohort (n = 56), the major complication was intraluminal hemorrhage (29%), and the median duration of hospitalization was 4 days (range 2-17 days). The presence of biliary obstruction, manifested as jaundice (p < 0.01), abnormal liver biology test results (p = 0.022), or biliary duct dilatation during endoscopic ultrasound (p < 0.001), was significantly higher in the EP R1 group (n = 20) than in the EP R0 (n = 16) group. After PD (n = 92), Clavien-Dindo ≥ 3 complications occurred in 28 patients (31%), and the 90-day mortality rate was 5.5%. Postoperative outcomes were similar between the EP + PD (n = 20) and uPD (n = 72) groups. Regarding endoscopic and surgical resection for early stage (T1-T2) adenocarcinoma, there was no significant difference in OS (p = 0.074) and DFS (p = 0.16) between groups. The median survival was not reached.

EP before complementary PD did not increase the incidence of postoperative complications or mortality rate. However, complementary PD after R1 EP did not improve long-term outcomes.