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Objective: Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA., Design: Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ 2 test, Mann-Whitney-U-test and log-rank test for survival., Results: Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable., Conclusions: The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further., Competing Interests: Competing interests: MH: Honoraria from FUJIFILM for lectures and expert panel. Honoraria from Falk Foundation for lectures. MBruno: Boston Scientific: consultant (money to institution), support for industry and investigator-initiated studies. Cook Medical: consultant (money to institution), support for industry and investigator-initiated studies. Pentax Medical: consultant (money to institution), support for investigator-initiated studies. Mylan: lecturer, support for investigator-initiated studies. ChiRoStim: support for investigator-initiated studies.MDC received a research grant Boston from Haemonetics,INC and he is co-PI of a Boston Scientific sponsored study, (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Cytoplasmic male sterility (CMS) originates from a mito-nuclear conflict where mitochondrial genes induce male sterility and nuclear genes restore male fertility in hermaphrodites. The first observation of CMS in animals was reported recently in the freshwater snail Physa acuta where it is associated with two extremes divergent mitotypes D and K. The D individuals are male-steriles while male fertility is restored by nuclear genes in K and are found mixed with the most common male-fertile N mitotype in natural populations (i.e. gynodioecy). We compared male and female fitness, growth rate and metabolism between the three mitotypes at two temperatures as this factor influences CMS in gynodioecious plants via alteration of mitochondrial functioning. Temperature did not affect male sterility which depended only on the mitotype and the presence of restorers. Our results provided evidence that CMS is beneficial to female fitness in the absence of restorers while it is costly in their presence, and furthermore driven by body mass, fulfilling a key theoretical condition for the long-term maintenance of gynodioecy. Fitness benefits and costs mediated by differences in body mass are enhanced at cold temperature, suggesting that the system dynamics may vary according to thermal conditions in nature.