1 Signs + Present, - Absent, X Not Done
Demographic, clinical, radiological and pathology details of the 29 patients with unexpected benign disease on pancreaticoduodenectomy for suspected periampullary and pancreatic carcinoma.
SNo / Age / Sex / Symptoms 1 / PastHistory 2 / CT
characteristics3 / MRI/MRCP characteristics3 / EUS3 / ERCP/SVE4 / Technique
cytology5 / Preoperative cytology 6 / Findings / JC decision 7 / Final HP 8
P / J / I / F / WL / D / DM / CP / CB / CA / SD / DD / M / CM / LN / SD / DD / M / CM / LN / M / WT / LN / S / AT
1 / 40 / F / - / + / - / - / - / - / - / - / - / - / + / - / + / - / + / x / x / x / x / x / + / - / - / + / - / P- FNAC / Indeterminate / Atypia / M-HOPM / CP
2 / 45 / M / + / + / - / - / - / - / - / - / - / + / + / - / + / - / - / x / x / x / x / x / + / - / + / + / - / P-FNAC / Indeterminate / Atypia / M-HOPM / CAI
3 / 65 / M / - / - / + / + / - / - / - / - / - / - / + / - / - / - / - / + / - / - / - / - / - / + / + / + / - / P-FNAC / Malignant / Adenocarcinoma / M-BDS / CBI
4 / 36 / F / + / + / - / + / - / - / - / - / + / - / + / - / - / - / - / x / x / x / x / x / + / - / + / + / - / BC/EB / Suspicious
malignant / Adenocarcinoma / M-BDS / CC
5 / 65 / F / + / + / - / + / - / - / - / - / + / - / + / - / + / - / - / + / - / - / - / - / + / + / - / + / - / Not done / M-BDS / CBI
6 / 53 / F / + / + / - / - / - / - / - / - / - / - / + / + / + / - / - / x / x / x / x / x / x / x / x / + / - / BB / Benign negative / No malignant cells / M-BDS / CP
7 / 50 / M / + / - / - / - / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / x / x / x / + / + / EB / Benign inflammatory / Chronic inflammation / M-PAM / CP
8 / 60 / F / + / - / - / - / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / x / x / x / x / x / Not done / M-HOPM / CP
9 / 66 / M / - / + / + / - / + / - / - / - / - / - / + / - / - / - / - / x / x / x / x / x / + / - / - / + / - / BC / Benign negative / No malignant cells / M-BDS / CP
10 / 52 / M / - / + / - / - / + / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / x / x / x / + / + / EB / Suspicious
malignant / Adenocarcinoma / M-PAM / CP
11 / 68 / M / + / + / - / - / - / - / - / + / - / + / - / - / - / - / - / x / x / x / x / x / + / - / - / x / x / Not done / M-HOPM / CP
12 / 52 / M / + / - / - / - / + / - / - / - / - / - / + / + / + / - / - / x / x / x / x / x / x / x / x / + / - / P-FNAC / Inadequate / Paucicellular / M-HOPM / CP
13 / 44 / F / + / - / - / - / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / + / - / - / x / x / Not done / M-HOPM / CP
14 / 72 / F / + / - / - / - / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / x / x / x / + / - / EB / Malignant / Adenocarcinoma / M-PAM / CP
15 / 55 / M / - / + / - / - / - / - / - / - / - / - / - / - / + / - / - / x / x / x / x / x / + / - / - / x / x / P-FNAC / Malignant / Adenocarcinoma / M-HOPM / CP
16 / 35 / M / + / - / - / - / - / - / + / - / - / + / - / - / - / - / - / x / x / x / x / x / x / x / x / + / - / BB / Suspicious malignant / Adenocarcinoma / M-BDS / CC
17 / 44 / F / + / + / + / - / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / + / - / - / - / - / Not done / M-BDS / CBI
18 / 64 / F / + / - / - / + / - / - / - / - / - / - / + / - / + / - / - / x / x / x / x / x / + / - / - / x / x / Not done / M-BDS / CBI
19 / 66 / M / + / + / + / - / - / - / - / - / - / - / + / - / - / - / x / x / x / x / x / + / - / - / + / - / EB /BB / Benign
inflammatory / Chronic inflammation / M-PAM / CBI
20 / 55 / F / + / + / - / - / - / - / - / - / - / - / + / + / - / - / x / x / x / x / x / x / x / x / + / - / BB / Indeterminate / Dysplasia / M-PAM / CBI
21 / 44 / F / + / - / - / - / - / - / - / - / - / - / + / - / - / - / - / x / x / x / x / x / x / x / x / + / + / EB / Suspicious malignant / Adenocarcinoma / M-PAM / CAI
22 / 35 / F / + / - / - / - / - / - / - / - / - / - / - / - / - / + / - / x / x / x / x / x / x / x / x / + / - / P-FNAC / Potentially malignant / Mucinous neoplasm / M-HOPC / PC
23 / 53 / M / + / + / + / - / - / - / + / - / - / - / + / + / + / - / - / x / x / x / x / x / x / x / x / + / + / EB / Benign
neoplastic / Adenoma / M-PAM / CP with AA
24 / 55 / M / + / - / - / + / - / - / - / - / - / - / + / + / + / - / - / x / x / x / x / x / x / x / x / + / + / EB / Malignant / Adenocarcinoma / M-PAM / AA
25 / 46 / M / - / + / - / - / - / - / - / - / - / - / + / - / + / - / - / + / - / + / - / - / x / x / x / + / + / EB / Benign neoplastic / Adenoma / M-PAM / AA
26 / 67 / F / + / - / - / + / - / - / - / - / - / - / + / - / + / - / - / + / + / + / - / - / x / x / x / + / + / Not done / M-PAM / AAM
27 / 69 / M / + / - / - / - / - / - / - / - / - / - / + / + / + / - / - / x / x / x / x / x / x / x / x / + / + / EB / Benign neoplastic / Adenoma / M-PAM / AA
28 / 19 / M / + / - / - / - / - / - / - / - / - / - / - / - / - / + / - / x / x / x / x / x / x / x / x / x / x / P-FNAC / Potentially malignant / Mucinous neoplasm / M-HOPC / CL
29 / 64 / M / + / - / - / - / - / - / - / - / - / - / - / - / - / + / - / x / x / x / x / x / x / x / x / x / P-FNAC / Potentially malignant / Mucinous neoplasm / M-HOPC / SC
1 Signs + present, - absent, x not done
2 Symptom A-abdominal pain, J- Jaundice, I-Itching, F-fever, WL- weight loss, D-Diarrhea, DM-Diabetes
mellitus
3 Past history CA-chronic alcoholic, CB-chronic biliary disease, CP-chronic pancreatitis
4 CT/MRI/EUS characteristics SD- single biliary duct dilatation DD-double duct ie biliary duct and
pancreatic duct dilatation M-discrete mass highly suggestive of malignancy, CM- cystic mass head
highly suggestive of mucinous neoplasm LN –enlarged lymph nodes WT – wall thickening bile duct
5 ERCP/SVE S-biliary stricture AT-ampullary tumour
6 Technique preoperative pathology P-FNAC-pancreas FNAC, BC-biliary cytology, BB-biliary brushings,
EB-Endoscopic ampullary biopsy
7 Preoperative pathology result AA-ampullary adenoma, AAM-ampullary adenomyoma, PC-pseudocyst,
SC-serous cystadenoma, CL-cystic lymphangioma, CC-choledochal cyst with atypia
8 MDT decision M-HOPM- malignant head of pancreas mass, M-HOPC-mucinous head of pancreas cyst,
M-PAM-malignant periampullary mass, M-BDS- malignant bile duct stricture
9 Final pathology result CP- chronic pancreatitis, AA-ampullary adenoma, AAM-ampullary adenomyoma,
PC-pseudocyst, SC-serous cystadenoma, CL-cystic lymphangioma, CC-choledochal cyst with atypia
CBI- chronic fibrosing biliary duct inflammation, CAI-chronic ampullary inflammation
Table 3
Analysis of preoperative diagnostic testing in the 29 patients with unexpected benign disease after pancreaticoduodenectomy for suspected periampullary and pancreatic carcinoma.
Procedure / n / False positive %CT scan / 29
Discrete mass/
Premalignant cystic mass / 19 / 65.51%
Double duct sign / 6 / 20.68%
Biliary duct dilatation / 23
MR scan / 4
Discrete mass / 2 / 50%
Double duct sign / 2 / 50%
Biliary dilatation / 4
ERCP / 17
Suspicious biliary stricture / 17 / 100%
EUS / 10
Discrete mass / 8 / 80%
Irregular wall thickening / 2
Pathology / 22
Malignant/ suspicious malignant/ mucinous cystic / 5/4/2 / 50%
Table 4
Analysis of preoperative diagnostic testing in the 29 patients with unexpected benign disease after pancreaticoduodenectomy for suspected periampullary and pancreatic carcinoma.
Variable / Benign / Malignant / Univariate P value / Multivariate P value / 95% CIAge / 53.7 / 53.43 / 0.874 / 0.920 / 0.966 / 1.032
Gender / 0.299 / 0.794 / 0.651 / 3.146
Male / 16 / 270
Female / 13 / 147
Surgical procedure / 0.780 / 0.735 / 0.148 / 15.057
PPPD/ Standard Whipples / 28 / 398
Vascular resection/ Multivisceral resection / 1 / 19
Blood loss / 1051.72 / 981.38 / 0.765 / 0.497 / 1.000 / 1.000
Overall complications / 0.332 / 0.476 / 0.443 / 5.721
Present / 12 / 36
Absent / 17 / 281
Postoperative pancreatic fistula / 0.019 / 0.104 / 0.029 / 1.391
Present / 9 (3.1%) / 61 (14.6%)
Absent / 20 / 356
Significant pancreatic fistula (B/C) / 0.065 / 0.616 / 0.267 / 9.266
Present / 7 (2.4%) / 51 (12.2%)
Absent / 22 / 366
Mortality / 0.043 / 0.341 / 0.082 / 1.415
No / 26 (10.3%) / 404 (3.1%)
Yes / 3 / 13
Table 5
Distribution of the number of surgeries and percentage of unexpected benign pathologic findings per year during the period of the study.
Year of Surgery / Total number of pancreaticoduodenectomies performed / Total number of patients with unexpected benign pathology / Percentage of patients with unexpected benign pathologyApril to December 2006 / 13 / 1 / 7.1 %
January to December 2007 / 37 / 0 / 0
January to December 2008 / 32 / 3 / 8.6 %
January to December 2009 / 45 / 1 / 2.2 %
January to December 2010 / 55 / 3 / 5.2 %
January to December 2011 / 69 / 6 / 8 %
January to December 2012 / 67 / 4 / 5.6 %
January to December 2013 / 99 / 11 / 10 %
Figure 2
Percentage of unexpected benign disease at pancreaticoduodenectomy for presumed malignant disease. per year.
Table 6
Details of series in literature of ‘unexpected’ benign disease after pancreaticoduodenectomy for presumed malignant disease
Series in literature / Indication for PD / Patients withbenign disease / Details of benign disease
Thompson et al 1994 (8) / Surgery for suspected periampullary malignancy / 7/20
35% / Chronic pancreatitis
Smith et al 1994
(Mayo clinic)(9) / Surgery for primary pancreatic or periampullary malignancy / 29/603
5% / Benign bile duct stricture, penetrating duodenal ulcer, metastatic melanoma, ampullary adenoma, intrahepatic drug-induced cholestasis and pseudocyst
Barens et al 1996
(John Hopkins)(10) / Surgery for suspected periampullary malignancy / 108/510
21% / Chronic pancreatitis, serous or mucinous or papillary cystic neoplasm, benign islet cell tumours, ampullary adenoma, duodenal leiomyoma, duodenal villous adenoma, duodenal adenomyoma.
van Gulik et al 1997
(Netherlands)(11) / Surgery for pancreatic head cancer / 14/220
6% / Inflammatory lesion in the pancreas or distal common bile duct
Abraham et al 2003
(John Hopkins)(12) / Surgery for suspected pancreatic head cancer / 40/447
9.2 % / Pancreatitis (gall stone induced, alcohol induced), chronic pancreatitis, benign biliary tract disease, lymphoplasmacytic sclerosing pancreatitis
Weber et al 2003(Memorial Sloan Kettering)(13) / Surgery for pancreatic head cancer / 1287
4.5 % / Pancreatitis
Kennedy et al 2006
(Maywood)(14) / Suspected pancreatic and periampullary cancer / 21/162
12.9 % / Pancreatitis and chronic bile duct inflammation
Kavanagh et al 2008
(Ireland, UK)(15) / Surgery for suspected periampullary malignancy / 8/112
7.1 % / Benign biliary stricture , chronic
pancreatitis , choledochal cyst, inflammatory pseudotumour, cystic
duodenal wall dysplasia , duodenal angiodysplasia , and granular cell
neoplasm.
de Castro et al 2009
(Netherlands)(17) / Suspicious pancreatic head mass / 63/639
9.9 % / Focal chronic pancreatitis, lymphoplasmactic sclerosing pancreatitis
de la Fuente 2010
(USA)(18) / Surgery for suspected pancreatic malignancy / 37/494
7.4 % / Pancreatitis, benign cystadenoma with superimposed pancreatitis
Manzia et al 2010
(UK)(19) / Surgery for suspected pancreatic and periampullary malignancy / 49/459
10.6% / Chronic pancreatitis, benign biliary stricture, choledochal cyst, adenomyoma ampulla, inflammation ampulla, papillary hyperplasia, ampullary adenoma, pseudotumour, bile duct papilloma, bile duct vascular malformation, duodenal ulcer
Hurtuk et al 2010
(USA)(20) / Surgery for suspected
periampullary cancer / 45/461
9.7% / Chronic pancreatitis, primary scelorosing cholangitis, choledocholithiasis, isolated bile duct stricture, ampulla of Vater ulcer, duodenal ulcer, distal common bile duct stricture with localized pancreatic fibrosis.
van Heerde 2012
(Netherlands)(21) / Surgery for suspected periampullary and pancreatic head malignancy / 36/274
13.1 % / Crohns, papillary fibrosis, biliary tract disease, chronic pancreatitis, benign neoplasms
1