Early-Stage Ampullary Cancer: Is Local Excision an Effective Alternative to Radical Resection?

BACKGROUND: The efficacy of local excision (transduodenal or endoscopic ampullectomy) in treating early-stage ampullary cancer has not been well defined. STUDY DESIGN: We queried the National Cancer Database to identify patients undergoing either local tumor excision or radical resection for early-stage (cTis-T2, N0, M0) ampullary adenocarcinoma between 2004 and 2018. Cox modeling was used to identify factors associated with overall survival. Patients undergoing local excision were then 1:1 propensity score-matched for demographics, hospital level, and histopathological factors to those undergoing radical resection. The Kaplan-Meier method was used to compare overall survival (OS) profiles for matched cohorts. RESULTS: A total of 1,544 patients met inclusion criteria. A total of 218 (14%) underwent local tumor excision, and 1,326 (86%) radical resection. On propensity score matching, 218 patients undergoing local excision were successfully matched to 218 patients undergoing radical resection. On comparison of matched cohorts, those undergoing local excision had lower rate of margin-negative (R0) resection (85.1% vs 99%, p < 0.001) and lower median lymph node count (0 vs 13, p < 0.001) but had significantly shorter length of initial hospitalization (median days: 1 vs 10 days, p < 0.001), lower rate of 30-day readmission (3.3% vs 12.0%, p = 0.001), and lower rate of 30-day mortality (1.8% vs 6.5%, p = 0.016) than patients undergoing radical resection. There was no statistically significant difference in OS between the matched cohorts (46.9% vs 52.0%, p = 0.46). CONCLUSIONS: In patients presenting with early-stage ampullary adenocarcinoma, local tumor excision is associated with higher rate of R1 resection but accelerated postprocedure recovery and patterns of OS comparable with those after radical resection. ( J Am Coll Surg 2023;237:146-156. (c) 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)