Multi-Institutional Analysis of Pancreatoduodenectomy for Nonfamilial Periampullary Adenoma: A Novel Risk Score to Guide Shared Decision-Making

Parit T Mavani; Caitlin Sok; Nina Eng; Angelo Marra; Laleh Foroutani; Adnan Alseidi; Hussein Hariri; Gregory Wilson; Syed A Ahmad; Charles Scoggins; Caitlin Hester; Jashodeep Datta; Nipun Merchant; Michael LeCompte; Hong Jin Kim; Gregory Sigler; Nabeel Zafar; Sharon Weber; Orjola Prela; Darren Carpizo; Christina Kasting; Ryan Fields; Juan M Sarmiento; Maria C Russell; Mihir M Shah; Shishir K Maithel; David A Kooby

doi:10.1097/XCS.0000000000001289

Multi-Institutional Analysis of Pancreatoduodenectomy for Nonfamilial Periampullary Adenoma: A Novel Risk Score to Guide Shared Decision-Making

J Am Coll Surg. 2025 Jan 20. doi: 10.1097/XCS.0000000000001289. Online ahead of print.

Authors

Parit T Mavani¹, Caitlin Sok¹, Nina Eng², Angelo Marra³, Laleh Foroutani⁴, Adnan Alseidi⁴, Hussein Hariri⁵, Gregory Wilson⁵, Syed A Ahmad⁵, Charles Scoggins⁶, Caitlin Hester⁷, Jashodeep Datta⁷, Nipun Merchant⁷, Michael LeCompte⁸, Hong Jin Kim⁸, Gregory Sigler⁹, Nabeel Zafar⁹, Sharon Weber⁹, Orjola Prela¹⁰, Darren Carpizo¹⁰, Christina Kasting¹¹, Ryan Fields¹¹, Juan M Sarmiento¹, Maria C Russell¹, Mihir M Shah¹, Shishir K Maithel¹, David A Kooby¹

Affiliations

¹ Department of Surgery, Emory University School of Medicine, Atlanta, GA.
² Department of Surgery, Pennsylvania State University School of Medicine, Hershey, PA.
³ Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA.
⁴ Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA.
⁵ Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
⁶ Department of Surgery, University of Louisville School of Medicine, Louisville, KY.
⁷ Department of Surgery, University of Miami School of Medicine, Miami, FL.
⁸ Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
⁹ Department of Surgery, University of Wisconsin School of Medicine, Madison, WI.
¹⁰ Department of Surgery, University of Rochester Medical Center, Rochester, NY.
¹¹ Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, MO.

PMID: 39831703
DOI: 10.1097/XCS.0000000000001289

Abstract

Introduction: Pancreatoduodenectomy (PD) may occasionally be indicated for complete removal of periampullary (duodenal and ampullary) adenomas (PAs). As compared with malignant indications, PD for benign or pre-malignant disease is often associated with increased morbidity. While the Spigelman classification assesses malignancy risk for familial adenomatous polyposis (FAP)-related duodenal adenomas, no malignancy risk score (MRS) exists for non-FAP related PAs. We developed a MRS for non-FAP related PAs undergoing PD to weigh risk of malignancy and postoperative morbidity.

Methods: We retrospectively analyzed patients with non-FAP related PA who underwent PD at eight institutions (2010-2022). Patient and lesion factors associated with final malignant pathology were identified using multivariable logistic regression to create MRS. Postoperative complications were assessed according to MRS.

Results: Of 127 patients, 59 (46.5%) had evidence of malignancy on final pathology. The odds of malignancy were higher in patients with older age ≥65 years (OR3.2, p=0.01), bile duct ≥9mm (OR3.3, p=0.009), preoperative symptoms (OR7.7, p=0.002), and high-grade dysplasia (HGD, OR7.5, p<0.001). A MRS was derived ranging from 0 to 6: age≥65=1, bile duct≥9mm=1, symptomatic=2, HGD=2. Patients were stratified into low (MRS1-2, n=26), intermediate (MRS3-4, n=59), and high-risk groups (MRS5-6, n=26), with malignancy rates increasing with MRS (10.3%, 44.1%, and 88.2%, p<0.001). Patients in the no/low-risk group (MRS0-2) had higher odds of major postoperative complications compared with patients in the intermediate/high-risk group (MRS≥3, OR2.9, p=0.047).

Conclusion: This novel MRS stratifies the risk of malignancy in non-FAP related PAs managed with PD. This score can be used to counsel patients who may require PD for complete tumor removal about their risk of harboring malignancy and their risk of major postoperative complications.