Pancreaticoduodenectomy

Abstract

Hypothesis: Pancreaticoduodenectomy (PD) is a safe procedure for a variety of periampullary conditions. Design: Retrospective review of a prospectively collected database. Setting: Academic tertiary care hospital. Patients: A total of 516 consecutive patients who underwent PD. Main Outcome Measures: Patient outcomes and survival factors. Results: Pathological examination demonstrated 57% periampullary cancers, 22% chronic pancreatitis, 12% cystic neoplasms, 4% islet cell neoplasms, and 5% other. Fiftyone percent of patients underwent pylorus preservation. Median operating time was 5 hours; blood loss, 1300 mL; and transfusion requirement, 1.5 U. Postoperative complications occurred in 43% of patients, including cardiopulmonary events (15%), fistula (9%), delayed gastric emptying (7%), and sepsis (6%). Additional surgery was required in 3% of patients, most commonly because of bleeding. Perioperative mortality was 3.9% overall but only 1.8% in patients with chronic pancreatitis; 25% of patients who died had preoperative complications associated with their periampullary condition. Three-year survival was 15% after resection for pancreatic cancer, 42% for duodenal cancer, 53% for ampullary cancer, and 62% for bile duct cancer. Univariate predictors of long-term survival in patients with periampullary adenocarcinoma included elevated glucose levels, liver function test results, abnormal tumor markers, blood loss, transfusion requirement, type of operation, and pathologic findings (periampullary adenocarcinoma type, differentiation, and margin and node status). Multivariate predictors were serum total bilirubin level, blood loss, operation type, diagnosis, and lymph node status. Conclusions: Pancreaticoduodenectomy continues to be associated with considerable morbidity. With careful patient selection, PD can be performed safely. Long-term survival in patients with periampullary adenocarcinoma can be predicted by preoperative laboratory values, intraoperative factors, and pathologic findings.

Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan

“…However, morbidity was still high at 41.56%, and it was not excellent compared with that reported in other institutional or national reports 2, 3, 4, 13. A PF remained the leading cause of total complications; in particular, a PF with an ISGPF grade C was associated with 76.47% of all C–D grades IV–V complications and it significantly resulted in the occurrence of a serious morbidity.…”

“…Although clinically relevant PF (an ISGPF grade B or C) commonly occurs in about 20% of patients undergoing PD, the occurrence of a PF grade C is very rare 1, 2, 3, 4. The development of a PF grade C is often associated with intra‐abdominal bleeding and can lead to mortality.…”

“…Recent advances in surgical techniques, interventional radiology, and perioperative intensive care support has reduced the mortality rate associated with PD to less than 5% 1, 2. However, the morbidity rate after PD remains high (38–44%) 2, 3, 4; it has not improved over recent decades, and it is much higher than morbidity rates following other surgical procedures for gastroenterological cancer 5, 6, 7. Clinically, the most relevant postoperative complication of PD is a pancreatic fistula (PF), which is often associated with the development of life‐threatening intra‐abdominal complications such as abscesses, early or delayed hemorrhage, the need for a relaparotomy, and death.…”

Analysis of procedure-related complications after pancreatodoudenectomy

“…The operation classically involves removal of the pylorus and antrum; however recently, surgeons have used a pylorus-preserving Whipple procedure to lower the incidence of postgastrectomy symptoms, such as delayed gastric emptying. Both methods -the standard and the pylorus-preserving Whipple-have their advocates, but each method continues to have gastroparesis as a postoperative problem [4,10,[20][21]. In our study, 11 (8.7%) of 126 patients underwent PD complicated delayed gastric emptying after operation.…”

“…Pancreatic fistula is the major source of complications, and leakage rate varies from 0-25%, according to recent reports [1,[4][5][8][9][10]. Abdominal abscess and hemorrhage are common sequelae of pancreatic anastomotic leakage, which have been associated with a mortality rate of 40% or more [9][10][11]. The complications after PD were classified as procedure-related (pancreatic leakage, biliary leakage, intraabdominal (IA) abscesses, hemorrhage, delayed gastric emptying) or general (pulmonary and cardiac).…”