R1 Endoscopic papillectomy for adenocarcinoma: is complementary pancreatoduodenectomy unavoidable?

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.