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

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.
(Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)