Diagnostic and therapeutic dilemmas in periampullary lesions.
OBJECTIVE
Periampullary lesions often present diagnostic and therapeutic dilemmas. This study is to clarify the justification of pancreaticoduodenectomy for the resectable periampullary lesion without histological confirmation of malignancy.


METHODS
Clinical data for periampullary lesions with presumed malignancy were retrieved from our prospectively-collected computer database. The surgical risks and test performance characteristics in diagnosis were determined.


RESULTS
There were 636 patients undergoing pancreaticoduodenectomy, including 572 with malignancy and 64 (10.1% false positive rate) with benign lesions. No resection was attempted for 32 patients, but 8 (25% false negative rate) eventually turned out to be malignant. Our data showed a sensitivity of 98.6% (572/580), a specificity of 27% (24/88) and an accuracy of 89.2% (596/668) in detecting periampullary malignancy. The surgical risks after pancreaticoduodenectomy were significantly lower in the benign group, with 28.1% morbidity (vs. 43.7% in the malignant group), no pancreatic leakage (vs. 11.5% in malignant group) and no surgical mortality (vs. 7.3% in the malignant group).


CONCLUSIONS
Pancreaticoduodenectomy is justified for a periampullary lesion without histological confirmation whenever malignancy is suspected. Moreover, a nihilistic approach could be associated with a significant false negative rate (25%) if left unresected and might preclude a patient with periampullary malignancy from cure.
Department of Surgery, National Yang Ming University, Taipei, Taiwan.
Pei-Jiun
PJ
Tsai
Shin-E
SE
Wang
Yi-Ming
YM
Shyr
Tien-Hua
TH
Chen
Cheng-Hsi
CH
Su
Chew-Wun
CW
Wu
D015746:Abdominal Pain / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000473:pathology* / Q000601:surgery; D001706:Biopsy; D016009:Chi-Square Distribution; D003138:Common Bile Duct Neoplasms / Q000150:complications / Q000473:pathology* / Q000601:surgery; D004379:Duodenal Neoplasms / Q000150:complications / Q000473:pathology* / Q000601:surgery; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007565:Jaundice / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications / Q000473:pathology* / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects; D050500:Pancreatitis, Chronic / Q000150:complications / Q000473:pathology / Q000601:surgery; D011237:Predictive Value of Tests; D018709:Statistics, Nonparametric; D015431:Weight Loss; D055815:Young Adult