Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation
J. I. Tsao, R. L. Rossi and J. A. Lowell
Department of General Surgery, Lahey Clinic, Burlington, Mass.
OBJECTIVE: To assess the adequacy of pylorus-preserving
pancreatoduodenectomy (PPPD) as a definitive surgical treatment for primary
malignant diseases of the periampullary region. DESIGN: Retrospective
review of the clinical records of patients undergoing PPPD for malignant
diseases of the periampullary region. Median and 5-year actuarial survival
by type and stage of cancer were determined. Survival data from this study
were compared with those of patients undergoing a conventional Whipple
operation. SETTING: Lahey Clinic, Burlington, Mass. STUDY PARTICIPANTS: One
hundred six patients undergoing PPPD for primary malignant disease of the
periampullary region between November 1979 and June 1992. INTERVENTION:
Pylorus-preserving pancreatoduodenectomy was performed with curative intent
in the 106 patients. Ninety-five patients underwent proximal
pancreatectomy; 11 patients, total pancreatectomy. Resection of the portal
vein was performed in 10 patients. MAIN OUTCOME MEASURE: Long-term survival
following PPPD was analyzed with respect to the type and stage of cancer.
Median follow-up was 30 months (range, 6 to 156 months). RESULTS: Five-year
actuarial survival rates were 45.4% for patients with ampullary
adenocarcinoma; 6.6%, with pancreatic ductal adenocarcinoma; 33.3%, with
distal bile duct adenocarcinoma; 75%, with pancreatic islet cell
adenocarcinoma; and 0%, with pancreatic cystadenocarcinoma. An early cancer
stage was associated with more favorable survival for ampullary and distal
bile duct adenocarcinomas. For pancreatic ductal adenocarcinoma only,
tumors less than 2 cm were associated with better survival. Duodenal
resection margins were free of disease in all patients, while
peripancreatic and retroperitoneal extension of the tumor was found in 20%.
CONCLUSION: For patients with periampullary malignant disease, long-term
survival following PPPD is similar to that following a conventional Whipple
operation. The potential benefits of hemigastrectomy with perigastric
lymphadenectomy are frequently obviated by the presence of positive margins
and lymph nodes elsewhere, ie, in the retroperitoneum. We advocate PPPD as
the procedure of choice for locally resectable malignant disease of the
periampullary region, provided the duodenal margin is viable and tumor
free.
