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Pancreaticoduodenectomy
A 20-Year Experience in 516 Patients
C. Max Schmidt, MD, PhD, MBA;
Emilie S. Powell, BA;
Constantin T. Yiannoutsos, PhD;
Thomas J. Howard, MD;
Eric A. Wiebke, MD;
Chad A. Wiesenauer, MD;
Joel A. Baumgardner, MD;
Oscar W. Cummings, MD;
Lewis E. Jacobson, MD;
Thomas A. Broadie, MD;
David F. Canal, MD;
Robert J. Goulet, Jr, MD;
Eardie A. Curie, PharmD;
Higinia Cardenes, MD;
John M. Watkins, BA;
Patrick J. Loehrer, MD;
Keith D. Lillemoe, MD;
James A. Madura, MD
Arch Surg. 2004;139:718-727.
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. Fifty-one 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.
From the Departments of Surgery (Drs Schmidt, Howard, Wiebke, Wiesenauer, Baumgardner, Jacobson, Broadie, Canal, Goulet, Lillemoe, and Madura and Ms Powell), Biostatistics (Dr Yiannoutsos), Pathology (Dr Cummings), Pharmacology (Dr Curie), Radiation Medicine (Dr Cardenes and Mr Watkins), and Medicine (Dr Loehrer) and the Indiana University Cancer Center (Drs Schmidt, Yiannoutsos, Howard, Wiebke, Cummings, Jacobson, Goulet, Loehrer, Lillemoe, and Madura), University Hospital, Indiana University School of Medicine, Indianapolis.
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