Implications of histological grade of tumour for the prognosis of radically resected periampullary adenocarcinoma.

OBJECTIVE: To study the influence of histological grade of tumour on the prognosis of radically resected periampullary cancers. DESIGN: Retrospective study. SETTING: Teaching hospital, Austria. SUBJECTS: 156 patients (papilla of Vater, n = 34, head of the pancreas, n = 105, and distal common bile duct, n = 17) who underwent partial pancreaticoduodenectomy for periampullary adenocarcinoma between 1 January, 1967 and 31 December, 1996. OUTCOME MEASURES: The relation between grade of tumour and site, T and N classification, extramural growth, invasion of vessels and resection margins, tumour volume, and survival time. RESULTS: Well differentiated lesions were significantly more common in the papilla of Vater (n = 15, 44%, p = 0.01) than in the pancreatic head or the common bile duct (n = 20, 19%, and n = 5, 29%, respectively). Only in ampullary lesions did the grade of tumour significantly affect the incidence of other histopathological risk factors (T p = 0.003; nodal status p = 0.01; extramural growth p = 0.0001; tumour volume p = 0.02) and survival time (p = 0.02); no significant correlations were found in cancers of the head of the pancreas or common bile duct. CONCLUSIONS: There was a significant difference in the distribution of grade of tumour between the different sites of origin of resected periampullary cancers. Grade of tumour correlated with T and N classification, tumour volume, extramural growth, and survival only in ampullary lesions.

Factors affecting mortality in transduodenal sphincteroplasty.

An analysis of 1,200 consecutive transduodenal sphincterotomies performed between 1967 and 1985 is presented herein. The over-all mortality rate was 3.75 per cent. Since 1980, however, the mortality rate has decreased to 2.1 per cent. The mortality rate was influenced by the age of the patient at the time of the operation (p less than 0.005). Furthermore, the mortality rate increased from decade to decade (less than 30 years, zero per cent; greater than 70 years, 6 per cent). The operative mortality rate was also influenced by general risk factors--hypertony (mortality rate of 5.8 per cent, not significant), diabetes (mortality rate of 6.5 per cent, p congruent to 0.05), renal failure (15.5 per cent, p less than 0.005), jaundice (bilirubin level in survivors, 78.3 micromoles per liter and in those who died, 120.4 micromoles per liter, p less than 0.005) and vital indication (mortality rate of 15 per cent, p less than 0.01). Although the indication for sphincterotomy had a small influence on the mortality (papilla stenosis without bile duct stones, 1.7 per cent; papilla stenosis with common duct stones, 3.6 per cent, and impacted stones in the papilla, 5.0 per cent), these small differences are not significant. A significant influence, however, was due to complicating intraoperative findings, such as bilioenteral fistulas (a mortality rate of 10.8 per cent, p less than 0.0005). The fact that the mortality rate increased in patients with T-tube insertion shows that operative problems and complications influence the mortality rate for sphincterotomy. From these results, we concluded that, in the aforementioned risk groups, a preoperative endoscopic sphincterotomy should be strongly considered, as the risk from the surgical procedure is diminished by the endoscopic relief of the obstruction of the biliary tract.