Pancreaticoduodenectomy for Pancreatic Head and Periampullary Adenocarcinoma Results of Surgical Treatment

Background and Purpose: Surgery remains the mainstay therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parentral nutrition have substantially decreased surgical complications and increased the survival. The aim of this prospective study is to analyze the surgical procedures, mortality and morbidity and survival data after pancreaticoduodenectomy (PD) for PH and PC and to evaluate the benefit of preoperative biliary drainage (PBD) and the technique of pancreaticogastrostomy (PG) and pylorus preserving pancreaticoduodenectomy (PPPD). Patients and Methods: From September 2000 to September 2003, 20 patients with PH and PC in NCI, Cairo University and South Egypt Cancer Institute (SECI), Assiut University were operated upon, (19 patients underwent pancreaticoduodenectomy while one patient underwent total pancreatectomy. Nine patients had pancreatic head tumors, 5 had ampullary tumors, 4 had tumors in the distal bile duct and 2 patients had tumors in the second part of the duodenum. Pylorus preservation was done in 7 patients. Pancreatic anastomosis was performed through pancreaticogastrostomy end to side in all cases except the case of total pancreatectomy (19), while biliary anastmosis was done as end-to-end choledecojejunostomy in 5 patients and end to side in 15 patients. Gastric anastmosis was fashioned as end-to-end gastrojejunostomy in 13 patients (including the 7 patients with pylorus preservation) and as end to side in 7 patients. Eight patients were subjected to preoperative biliary drainage with internal stents. Results: The age of the patients ranged from 23 to 64 years and the mean age was 52.3 years. Twelve patients (60%) were males while 8 patients (40%) were females. Fourteen patients (70%) had stage I and II cancer while 5 had stage III disease (25%) and 1 case had stage IV disease. Three patients died in the perioperative period (15%) Postoperative morbidity in the form of, minor biliary leakage in 4 patients (20%); 3 healed conservatively. Leakage from gastrointestinal anastomosis occurred in 2 patients (10%); one healed conservatively and the other was explored and closure of the site of leakage was done. Five patients (25%) had mild wound infection (four of 311 them with preoperative stenting). No complication was found in the pancreaticogastrostomy anastmosis. Delayed gastric emptying occurred in 6 patients (30%). The mean hospital stay was 17 days. The patients were followed up for a period ranged between 6 and 35 months. The median overall survival was 24 months while the median disease free survival was 22 month. At one year, the overall survival (OS) was 93.8% while, the disease free survival (DFS) was 92% while at 24 month, the OS was 47.7% and the DFS was 32%. During follow up 4 patients died: 2 with liver metastases and 2 due to unrelated causes, 1 patient is living with liver metastases and 2 living with recurrence. Ten patients (50%) were completely free at the end of follow up. Conclusions: Surgical resection remains the only modality to offer the possibility of long-term survival. All patients deemed suitable for surgery should be accurately staged with a combination of enhanced helical CT, dynamic MRI and MRCP, endosonography and laparoscopy. Pylorus preserving pancreaticoduodenctomy can be performed for better physiological function and it does not compromise survival though is associated with more delayed gastric emptying. Pancreaticogastrostomy is easy to perform and safe as regards the incidence of pancreatic fistula. Preoperative biliary drainage does not influence the incidence of postoperative complications except wound infection in spite of it can be performed safely in jaundiced patients, it should not be used routinely.