Pancreatoduodenectomy for resectable malignant periampullary tumors

The results of all 53 pancreatoduodenectomies performed at one hospital were reviewed for operative mortality, accuracy of operative diagnosis and long term survival. Although carcinomas of the ampulla are much more rare than those of the pancreas, the number of patients in our operative series with adenocarcinoma of the ampulla approached the number with adenocarcinoma of the pancreas, indicating that only those with small, early lesions of the head of the pancreas were considered to be appropriate candidates for pancreatoduodenectomy. Six of the 21 patients with carcinomas of the pancreas had histologically favorable tumors (three papillary adenocarcinomas, two cystadenocarcinomas and one islet cell carcinoma), although only one of these was correctly diagnosed preoperatively or intraoperatively. Eight patients had benign conditions, half of whom underwent planned resections for chronic pancreatitis. The over-all operative mortality for our series was 13.2 per cent. The operative diagnosis was incorrect in seven patients. Excluding cystadenocarcinomas and islet cell carcinomas, four patients with carcinoma of the pancreas survived five years and six patients with carcinoma of the ampulla survived five years, with corresponding survival periods of 2.5 and 5.1 years following pancreatoduodenectomy. We conclude that: 1, pancreatoduodenectomy should be used in a highly selective manner by surgeons experienced with such operations; 2, the high diagnostic error rate and the occurrence of histologically favorable tumors of the pancreas make the arbitrary exclusion of all tumors of the pancreas for resectional therapy an unsound policy, and 3, pancreatoduodenectomy remains the best therapy for resectable tumors of the periampullary region.