Adenomyoma of the ampulla of Vater mimicking malignancy: A case report and literature review.

RATIONALE: Adenomyoma is a rare reactive, hamartomatous benign tumor-like lesion. Although adenomyoma can occur anywhere in the gastrointestinal tract, including the gallbladder, stomach, duodenum, and jejunum, it is very rarely observed in the extrahepatic bile duct and ampulla of Vater (AOV). The preoperative accurate diagnosis of adenomyoma of the Vaterian system, including the AOV and common bile duct, is significant to appropriate patient management. However, discriminating between benign and malignancy is highly challenging. Patients are frequently mistaken as having periampullary malignancy, thereby leading to unnecessary extensive surgical resection with a high risk of complications. PATIENT CONCERNS: A 47-year-old woman visited a local hospital owing to epigastric and right upper-quadrant abdominal pain for 2 days. DIAGNOSES: Abdominal ultrasonography performed in the local hospital revealed suspicious of a distal common bile duct malignancy. She was transferred to our hospital for further evaluation and management. INTERVENTIONS: After consulting with the patient, a multidisciplinary team, including a gastroenterologist, finally decided to perform surgery under the impression of an ampullary malignancy, and pylorus-preserving pancreatoduodenectomy was performed without any complications. She was histopathologically diagnosed with an adenomyoma of the AOV. OUTCOMES: At the 5-year follow-up, she was well and did not develop further symptoms or complications. LESSONS: Although adenomyoma is very rare, it should be included in the differential diagnosis of mass-like lesions of the AOV to avoid unnecessary surgeries.

Development, validation, and comparison of a nomogram based on radiologic findings for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: An international multicenter study.

BACKGROUND: Although we previously proposed a nomogram to predict malignancy in intraductal papillary mucinous neoplasms (IPMN) and validated it in an external cohort, its application is challenging without data on tumor markers. Moreover, existing nomograms have not been compared. This study aimed to develop a nomogram based on radiologic findings and to compare its performance with previously proposed American and Korean/Japanese nomograms. METHODS: We recruited 3708 patients who underwent surgical resection at 31 tertiary institutions in eight countries, and patients with main pancreatic duct >10 mm were excluded. To construct the nomogram, 2606 patients were randomly allocated 1:1 into training and internal validation sets, and area under the receiver operating characteristics curve (AUC) was calculated using 10-fold cross validation by exhaustive search. This nomogram was then validated and compared to the American and Korean/Japanese nomograms using 1102 patients. RESULTS: Among the 2606 patients, 90 had main-duct type, 900 had branch-duct type, and 1616 had mixed-type IPMN. Pathologic results revealed 1628 low-grade dysplasia, 476 high-grade dysplasia, and 502 invasive carcinoma. Location, cyst size, duct dilatation, and mural nodule were selected to construct the nomogram. AUC of this nomogram was higher than the American nomogram (0.691 vs 0.664, P = .014) and comparable with the Korean/Japanese nomogram (0.659 vs 0.653, P = .255). CONCLUSIONS: A novel nomogram based on radiologic findings of IPMN is competitive for predicting risk of malignancy. This nomogram would be clinically helpful in circumstances where tumor markers are not available. The nomogram is freely available at http://statgen.snu.ac.kr/software/nomogramIPMN.

Utilization of end to side inverted mattress pancreaticojejunostomy for Duval procedure: A case report.

Although a pancreaticojejunostomy (PJ) is not required after a distal pancreatectomy in most cases, it needs to be performed to prevent atrophy of the remnant pancreas when the proximal duct is obstructed by a tumor, stone, or etc. In these conditions, the critical postoperative pancreatic fistula (POPF) gives surgeons cause to hesitate before performing a PJ. We previously presented the modified technique of Mattress PJ named "inverted mattress PJ" (IM-PJ) and published improved outcomes in the aspects of POPF after a pancreaticoduodenectomy and a central pancreatectomy. Recently, we had a case of a patient who has chronic pancreatitis with a proximal pancreatic duct obstruction, requiring a distal pancreatectomy and PJ. Based on the previous report, we decided to apply the "inverted mattress PJ" (IM-PJ) technique for a Roux-en Y PJ after a distal pancreatectomy. The patient was discharged after surgery without complications. We reviewed a case of a patient requiring PJ following a distal pancreatectomy and discussed the safety of our technique.

Various types of reconstruction after pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: a single-enter experience.

Purpose: The incidence of patients requiring pancreaticoduodenectomy (PD) following any type of gastrectomy is increasing as the population of elderly patients is increasing, especially in endemic areas of gastric cancer such as Korea. All types of gastrectomy can be categorized as subtotal gastrectomy with Billroth I (BI), Billroth II (BII), and total gastrectomy with Roux-en-Y anastomosis. In this paper, we reviewed our experiences of PD for patients who previously underwent gastrectomy. Methods: We reviewed the medical records of the patients who underwent PD following any type of gastrectomy among 505 consecutive patients who underwent PD in a single institution between 2011 and 2020 retrospectively. Results: There were 13 patients who had undergone gastrectomy including 7 patients of BI, 1 patient of BII, and 5 patients of total gastrectomy. For all 7 patients of BI, the reconstruction was not different from conventional PD. For the 1 patient of BII, previous gastrojejunal anastomosis was preserved and reconstruction was performed in Roux-en-Y method. For the 5 patients with total gastrectomy, 2 different types of reconstruction were performed. In one patient, we removed the remaining jejunum with the specimen, and reconstruction was performed. For the other 4 patients, the remaining jejunum, distal to the Treitz ligament, was preserved and was utilized for anastomosis. Surgeries for all patients were uneventful. Conclusion: PD following any type of gastrectomy can be safe. Especially, if the length of remained jejunum is long enough, its utilization for the reconstruction can be an appropriate option.

Unfavorable effect of high postoperative fluid balance on outcome of pancreaticoduodenectomy.

Purpose: Despite the many efforts to overcome postoperative complications, pancreaticoduodenectomy (PD) is still accompanied with considerable concerns of lethal complications. The clinical factors are known to affect postoperative outcomes such as diameter of pancreatic duct, texture of pancreas, and comorbidity of the patients are mostly uncorrectable. Thus, investigation for correctable risk factors is required. Recently, perioperative fluid volume was reported to be associated with complications after PD. This study aims to determine the relationship between postoperative fluid balance and surgical outcome after open PD. Methods: We reviewed, retrospectively, 172 consecutive patients who underwent open PD in a single institution between 2015 and 2019. The status of perioperative fluid balance 2 days after surgery and clinical factors were investigated to determine the association with postoperative outcome including postoperative pancreatic fistula (POPF). According to postoperative fluid balance, patients were divided into high- and low-balance groups, and clinical features and surgical outcomes were compared between both groups. Multivariate analysis were performed to identify risk factors for POPF. Results: The percentage of morbidity and the incidence of POPF were higher in the high-balance group compared to the low-balance group (61.6% vs. 37.2%, P = 0.001; 15.1% vs. 3.5%, P = 0.009). High postoperative fluid balance and the presence cardiovascular disease were correlated with POPF on multivariate analysis (odds ratio [OR], 4.574; 95% confidence interval [CI], 1.229-17.029; P = 0.023 and OR, 3.517; 95% CI, 1.209-12.017; P = 0.045). Conclusion: Higher amount of postoperative fluid balance and the presence of cardiovascular disease are associated with POPF after PD.

Malignant melanoma of the gallbladder: A case report and literature review.

Metastatic melanoma of the gallbladder is extremely rare. It has a poor prognosis. Its optimal treatment remains unclear. Surgical resection is generally considered the mainstay of treatment. However, there are no standards to guide the choice between open surgery and laparoscopic surgery. Criteria for the extent of surgical dissection have not been established yet either. We report a patient diagnosed with gallbladder cancer who underwent extended cholecystectomy but had metastatic melanoma at the final biopsy. We reviewed the literature on the treatment of metastatic melanoma in the gallbladder and compared it with our case to determine a treatment strategy.

Comparison of Oncologic Outcomes between Transduodenal Ampullectomy and Pancreatoduodenectomy in Ampulla of Vater Cancer: Korean Multicenter Study.

This study used multicenter data to compare the oncological safety of transduodenal ampullectomy (TDA) with that of pylorus-preserving pancreatoduodenectomy (PPPD) in early ampulla of Vater (AoV) cancer. Data for patients who underwent surgical resection for AoV cancer (pTis-T2 stage) from January 2000 to September 2019 were collected from 15 institutions. The clinicopathologic characteristics and survival outcomes were compared between the PPPD and TDA groups. A total of 486 patients were enrolled (PPPD, 418; TDA, 68). The oncologic behavior in the PPPD group was more aggressive than that in the TDA group at all T stages: larger tumor size (p = 0.034), advanced T stage (p < 0.001), aggressive cell differentiation (p < 0.001), and more lymphovascular invasion (p = 0.002). Five-year disease-free survival (DFS) and overall survival (OS) did not differ between the two groups when considering all T stages or only the Tis+T1 group. Among T1 patients, PPPD produced significantly better DFS (PPPD vs. TDA, 84.8% vs. 66.6%, p = 0.040) and superior OS (PPPD vs. TDA, 89.1% vs. 68.0%, p = 0.056) than TDA. Lymph node dissection (LND) in the TDA group did not affect DFS or OS (TDA + LND vs. TDA-only, DFS, p = 0.784; OS, p = 0.870). In conclusion, PPPD should be the standard procedure for early AoV cancer.

Risk prediction for malignant intraductal papillary mucinous neoplasm of the pancreas: logistic regression versus machine learning.

Most models for predicting malignant pancreatic intraductal papillary mucinous neoplasms were developed based on logistic regression (LR) analysis. Our study aimed to develop risk prediction models using machine learning (ML) and LR techniques and compare their performances. This was a multinational, multi-institutional, retrospective study. Clinical variables including age, sex, main duct diameter, cyst size, mural nodule, and tumour location were factors considered for model development (MD). After the division into a MD set and a test set (2:1), the best ML and LR models were developed by training with the MD set using a tenfold cross validation. The test area under the receiver operating curves (AUCs) of the two models were calculated using an independent test set. A total of 3,708 patients were included. The stacked ensemble algorithm in the ML model and variable combinations containing all variables in the LR model were the most chosen during 200 repetitions. After 200 repetitions, the mean AUCs of the ML and LR models were comparable (0.725 vs. 0.725). The performances of the ML and LR models were comparable. The LR model was more practical than ML counterpart, because of its convenience in clinical use and simple interpretability.

Optimal surgical treatment in patients with T1b gallbladder cancer: An international multicenter study.

BACKGROUND: There is no consensus on the optimal treatment of T1b gallbladder cancer (GBC) due to the lack of evidence and the difficulty of anatomy and pathological standardization. METHODS: A total of 272 patients with T1b GBC who underwent surgical resection at 14 centers with specialized hepatobiliary-pancreatic surgeons and pathologists in Korea, Japan, Chile, and the United States were studied. Clinical outcomes including disease-specific survival (DSS) rates according to the types of surgery were analyzed. RESULTS: After excluding patients, the 237 qualifying patients consisted of 90 men and 147 women. Simple cholecystectomy (SC) was performed in 116 patients (48.9%) and extended cholecystectomy (EC) in 121 patients (51.1%). The overall 5-year DSS was 94.6%, and it was similar between SC and EC patients (93.7% vs. 95.5%, P = 0.496). The 5-year DSS was similar between SC and EC patients in America (82.3% vs. 100.0%, P = 0.249) as well as in Asia (98.6% vs. 95.2%, P = 0.690). The 5-year DSS also did not differ according to lymph node metastasis (P = 0.688) or tumor location (P = 0.474). CONCLUSIONS: SC showed similar clinical outcomes (including recurrence) and survival outcomes as EC; therefore, EC is not needed for the treatment of T1b GBC.

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017.

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.

Effect of end-to-side inverted mattress pancreaticojejunostomy following central pancreatectomy on the prevention of pancreatic fistula.

PURPOSE: Central pancreatectomy (CP) may be indicated for the treatment of benign or low-grade malignant tumor in the neck and proximal body of the pancreas. Pancreatic fistula is one of the most common complications after CP. In this study, we suggested an inverted mattress pancreaticojejunostomy (IM-PJ) technique to decrease the risk of pancreatic fistula. METHODS: Between 2010 and 2015, CP was performed with IM-PJ for 10 consecutive patients with a benign or low-grade malignant tumor in the neck and proximal body of the pancreas. All clinical and pathological data were analyzed retrospectively. RESULTS: Median age was 56.4 years (range, 17-75 years). Median surgery duration was 286 minutes (range, 205-410 minutes). In all cases, the distal stump was reconstructed using the IM-PJ method. Median duration of hospital stay was 23.8 days (range, 9-53 days). No patient mortality occurred. Pancreatic fistula developed in 9 cases (90%); however, all fistulas were grade A and resolved without surgical or radiological intervention. Nine patients remain well with no recurrence or new endocrine or exocrine dysfunction. CONCLUSION: Our results demonstrate that the outcomes of CP with IM-PJ are reasonable for prevention of pancreatic fistula following CP.

Long-term outcomes and recurrence patterns of standard versus extended pancreatectomy for pancreatic head cancer: a multicenter prospective randomized controlled study.

BACKGROUND: Our previous randomized controlled trial revealed no difference in 2-year overall survival (OS) between extended and standard resection for pancreatic adenocarcinoma. The present study evaluated the 5-year OS and recurrence patterns according to the extent of pancreatectomy. METHODS: Between 2006 and 2009, 169 consecutive patients were prospectively enrolled and randomized to standard (n = 83) or extended resection (n = 86) groups to compare 5-year OS rate, long-term recurrence patterns and factors associated with long-term survival. RESULTS: The surgical R0 rate was similar between the standard and extended groups (85.5 vs. 90.7%, P = 0.300). Five-year OS (18.4 vs. 14.4%, P = 0.388), 5-year disease-free survival (14.8 vs. 14.0%, P = 0.531), and overall recurrence rates (74.7 vs. 69.9%, P = 0.497) were not significantly different between the two groups, although the incidence of peritoneal seeding was higher in the extended group (25 vs. 8.1%, P = 0.014). CONCLUSIONS: Extended pancreatectomy does not have better short-term and long-term survival outcomes, and shows similar R0 rates and overall recurrence rates compared with standard pancreatectomy. Extended pancreatectomy does not have to be performed routinely for all cases of resectable pancreatic adenocarcinoma, especially considering its associated increased morbidity shown in our previous study.

Proposed Nomogram Predicting the Individual Risk of Malignancy in the Patients With Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas.

OBJECTIVES: This study evaluated individual risks of malignancy and proposed a nomogram for predicting malignancy of branch duct type intraductal papillary mucinous neoplasms (BD-IPMNs) using the large database for IPMN. BACKGROUND: Although consensus guidelines list several malignancy predicting factors in patients with BD-IPMN, those variables have different predictability and individual quantitative prediction of malignancy risk is limited. METHODS: Clinicopathological factors predictive of malignancy were retrospectively analyzed in 2525 patients with biopsy proven BD-IPMN at 22 tertiary hospitals in Korea and Japan. The patients with main duct dilatation >10 mm and inaccurate information were excluded. RESULTS: The study cohort consisted of 2258 patients. Malignant IPMNs were defined as those with high grade dysplasia and associated invasive carcinoma. Of 2258 patients, 986 (43.7%) had low, 443 (19.6%) had intermediate, 398 (17.6%) had high grade dysplasia, and 431 (19.1%) had invasive carcinoma. To construct and validate the nomogram, patients were randomly allocated into training and validation sets, with fixed ratios of benign and malignant lesions. Multiple logistic regression analysis resulted in five variables (cyst size, duct dilatation, mural nodule, serum CA19-9, and CEA) being selected to construct the nomogram. In the validation set, this nomogram showed excellent discrimination power through a 1000 times bootstrapped calibration test. CONCLUSION: A nomogram predicting malignancy in patients with BD-IPMN was constructed using a logistic regression model. This nomogram may be useful in identifying patients at risk of malignancy and for selecting optimal treatment methods. The nomogram is freely available at http://statgen.snu.ac.kr/software/nomogramIPMN.

Outcomes and recurrence pattern after non-anatomic liver resection for solitary hepatocellular carcinomas.

BACKGROUNDS/AIMS: Anatomic resection (AR) is preferred for eradicating portal tributaries in patients with hepatocellular carcinoma (HCC). However, the extent of resection is influenced by underlying liver disease and tumor location. We compared the surgical outcomes and recurrence pattern between non-anatomic resection (NR) and AR. METHODS: From March 2009 to February 2012, 184 patients underwent surgical resection for HCC. Among these, 79 patients who were primarily treated for a single tumor without rupture or macroscopic vascular invasion were enrolled. The patients were divided into 2 groups based on the extent of resection: AR (n=31) or NR (n=48). We compared the clinical characteristics, overall survival, disease-free survival, pattern of recurrence, and biochemical liver functions during the perioperative period between the two groups. RESULTS: The extent of resection had no significant effect on overall or disease-free survival rates. The overall 1- and 3-year survival rates were 97% and 82% in the AR group, and 96% and 89% in the NR group, respectively (p=0.49). In addition, the respective 1- and 3-year disease-free survival rates for the AR and NR groups were 84% and 63%, and 85% and 65%, respectively (p=0.94). On the other hand, the presence of hepatic cirrhosis and a tumor size of >5 cm were significant risk factors for recurrence according to multivariate analysis (p<0.001 and p=0.003, respectively). The frequency of early recurrence, the first site of recurrence, and the pattern of intrahepatic recurrence were similar between the 2 groups (p=0.419, p=0.210, and p=0.734, respectively); in addition, the frequency of marginal recurrence did not differ between the 2 groups (1 patient in the AR group and 2 in the NR group). The NR group showed better postoperative liver function than the AR group. CONCLUSIONS: Non-anatomic liver resection can be a safe and efficient treatment for patients with a solitary HCC without rupture or gross vascular invasion.

Impact of clinically significant portal hypertension on surgical outcomes for hepatocellular carcinoma in patients with compensated liver cirrhosis: a propensity score matching analysis.

BACKGROUNDS/AIMS: The roles of portal hypertension (PHT) on the postoperative course after hepatectomy are still debated. The aim of this study was to evaluate surgical outcomes of hepatectomy in patients with PHT. METHODS: Data from 152 cirrhotic patients who underwent hepatectomy for hepatocellular carcinoma (HCC) were collected retrospectively. Patients were divided into two groups according to the preoperative presence of PHT as follows: 44 patients with PHT and 108 without PHT. Propensity score matching (PSM) analysis was used to overcome selection biases. RESULTS: There were no significant differences in morbidity (56.8% vs. 51.9%, p=0.578) and 90-days mortality (4.5% vs. 4.6%, p=0.982) between the two groups. Post-hepatectomy liver failure (PHLF) was not significantly different between the two groups (43.2% vs. 35.2%, p=0.356). Patients without PHT had a better 5-year disease-free survival than those with PHT, although the difference did not reach statistical significance (30.9% vs. 17.2%, p=0.081). Five-year overall survivals were not significantly different between the two groups (46.6% vs. 54.9%, p=0.724). Repeat analyses after PSM showed similar rates of morbidity (p=0.819), mortality (p=0.305), PHLF (p=0.648), disease-free survival (p=0.241), and overall survival (p=0.619). The presence of PHT was not associated with either short-term or long-term poor surgical outcomes. CONCLUSIONS: Child-Pugh A and B patients with PHT have surgical outcomes similar to those without PHT. Hepatectomy can be safely performed and can also be considered as a potentially curative treatment in HCC patients with PHT.

Distal pancreatectomy with celiac axis resection for pancreatic body and tail cancer invading celiac axis.

PURPOSE: Pancreatic body/tail cancer often involves the celiac axis (CA) and it is regarded as an unresectable disease. To treat the disease, we employed distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and reviewed our experiences. METHODS: We performed DP-CAR for seven patients with pancreatic body/tail cancer involving the CA. The indications of DP-CAR initially included tumors with definite invasion of CA and were later expanded to include borderline resectable disease. To determine the efficacy of DP-CAR, the clinico-pathological data of patients who underwent DP-CAR were compared to both distal pancreatectomy (DP) group and no resection (NR) group. RESULTS: The R0 resection rate was 71.4% and was not statistically different compared to DP group. The operative time (P = 0.018) and length of hospital stay (P = 0.022) were significantly longer in DP-CAR group but no significant difference was found in incidence of the postoperative pancreatic fistula compared to DP group. In DP-CAR group, focal hepatic infarction and transient hepatopathy occurred in 1 patient and 3 patients, respectively. No mortality occurred in DP-CAR group. The median survival time (MST) was not statistically different compared to DP group. However, the MST of DP-CAR group was significantly longer than that of NR group (P < 0.001). CONCLUSION: In our experience, DP-CAR was safe and offered high R0 resection rate for patients with pancreatic body/tail cancer with involvement of CA. The effect on survival of DP-CAR is comparable to DP and better than that of NR. However, the benefits need to be verified by further studies in the future.

The effects of the end-to-side inverted mattress pancreaticojejunostomy on postoperative pancreatic fistula: a single surgeon's experience.

PURPOSE: Various pancreaticojejunostomy (PJ) techniques have been devised to minimize the rate of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). This study describes a modification of the mattress suture PJ technique, which we call "inverted mattress PJ (IM)". The results of an IM group and a historical consecutive control group were compared to determine how the IM technique affected POPF. METHODS: From 2003 to 2010, 186 consecutive patients underwent PD. A former group of 52 consecutive patients who underwent conventional duct-to-mucosa PJ (DM) was used as a historical control group. The IM technique was utilized for the IM group (134 patients). The clinicopathological features and surgical outcomes of the 2 groups were compared, with a particular focus on postoperative POPFs. RESULTS: The average surgery duration was shorter in the IM group (580.3 minutes vs. 471 minutes, P < 0.001). Grades B and C POPFs occurred less frequently in the IM group, but the difference was not statistically significant (17.3% vs. 9.7%, P = 0.200). However, no grade C POPF occurred in the IM group compared with 5.8% of grade C POPFs (3/52) in the DM group (P = 0.020). Three patients died (1 in the DM group and 2 in the IM group). The causes of death were arrhythmia in 2 cases and Candida sepsis in 1 case. POPF was not causally related to the 3 deaths. CONCLUSION: IM end-to-side PJ shortened operation time and increased safety with no incidence of grade C POPF.

A rare case of gallbladder torsion along the axis of body: a case report.

Abnormal attachment of the gallbladder to the liver is the main cause for gallbladder torsion. However, the present study reports a rare case of gallbladder torsion in which a portion of fundus is rotated along the axis of body. So far, very few similar cases have been reported. An 87-year-old woman complaining right upper quadrant abdominal pain for 4 days was admitted. Her body temperature was 38.5℃ with moderate dehydration. A large tender mass was palpated on the right abdomen extending to the right iliac fossa. Computed tomography of abdomen showed a large cavity with a diameter of 15 cm containing a big stone and a small normal looking gallbladder. Ultrasonographic scan showed a twisted portion of the gallbladder torsion. During emergency laparotomy, the middle portion of the gallbladder was found to be twisted counterclockwise with huge gangrenous gallbladder distal. The proximal body of the gallbladder was spared and attached firmly to the liver. Cholecystectomy was performed and the patient was discharged 2 weeks later without postoperative complications. Histological findings of specimen were consistent with operative findings. The current study reports on a rare case of gallbladder torsion by reviewing previous studies.

Prognostic factors in patients with middle and distal bile duct cancers.

AIM: To identify the influence of the surgery type and prognostic factors in middle and distal bile duct cancers. METHODS: Between August 1990 and June 2011, data regarding the clinicopathological factors of 194 patients with surgical and pathological confirmation were collected. A total of 133 patients underwent resections (R0, R1, R2; n = 102, 24, 7), whereas 61 patients underwent nonresectional surgery. Either pancreaticoduodenectomy (PD) or bile duct resection (BDR) was selected according to the sites of tumors and co-morbidities of the patients after confirming resection margin by the frozen histology in all cases. Univariate and multivariate analyses of clinicopathologic factors were performed, utilizing the Kaplan-Meyer method and Cox hazard regression analysis. RESULTS: The overall 5-year survival rate for the 133 patients who underwent resection (R0, R1, and R2) was 41.2%, whereas no patients survived longer than 3 years among the 61 patient who underwent nonresectional surgeries. The 5-year survival rate of the patients who underwent a PD (n = 90) was higher than the rate of those who underwent BDR (n = 43), although the difference was not statistically significant (46.6% vs 30.0% P = 0.105). However, PD had a higher rate of R0 resection than BDR (90.0% vs 48.8%, P < 0.0001). If R0 resection was achieved, PD and BDR showed similar survival rates (49.4% vs 46.5% P = 0.762). The 5-year survival rates of R0 and R1 resections were not significantly different (49.0% vs 21.0% P = 0.132), but R2 resections had lower survival (0%, P = 0.0001). Although positive lymph node, presence of perineural invasion, presence of lymphovascular invasion (LVI), 7th AJCC-UICC tumor node metastasis (TNM) stage, and involvement of resection margin were significant prognostic factors in univariate analysis, multivariate analysis identified only TNM stage and LVI as independent prognostic factors. CONCLUSION: PD had a greater likelihood of curative resection and R1 resection might have some positive impact. The TNM stage and LVI were independent prognostic factors.