Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors

Background: Pancreaticoduodenectomy(PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival( ≥ 5 years) after PD. Methods: This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group(I) patients who survived less than 5 years and group(II) patients who survived ≥ 5 years. Results: There were 47(20.6%) long-term survivors( ≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31(66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR(95% CI) = 1.712(1.24 8–2.34 8), P = 0.001], smaller tumor size [OR(95% CI) = 1.335(1.032–1.726), P = 0.028] and R0 resection [OR(95% CI) = 3.098(2.095–4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%. Conclusions: The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Biliary leakage following pancreaticoduodenectomy:Prevalence,risk factors and management

Background: Few studies investigated biliary leakage after pancreaticoduodenectomy(PD) especially when compared to postoperative pancreatic fistula(POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. Methods: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group(1) included patients who developed biliary leakage and group(2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. Results: The study included 555 patients. Forty-four patients(7.9%) developed biliary leakage. Ten patients(1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography(ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients(90.9%). Only 4 patients(9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group(6.8% vs 3.9%, P = 0.05). Conclusions: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM:To elucidate surgical outcomes of pancreaticoduodenectomy(PD)in patients with liver cirrhosis.METHODS:We studied retrospectively all patients who underwent PD in our centre between January 2002and December 2011.Group A comprised patients with cirrhotic livers,and Group B comprised patients with non-cirrhotic livers.The cirrhotic patients had ChildPugh classes A and B(patient’s score less than 8).Preoperative demographic data,intra-operative data and postoperative details were collected.The primary outcome measure was hospital mortality rate.Secondary outcomes analysed included duration of the operation,postoperative hospital stay,postoperative morbidity and survival rate.RESULTS:Only 67/442 patients(15.2%)had cirrhotic livers.Intraoperative blood loss and blood transfusion were significantly higher in group A(P=0.0001).The mean surgical time in group A was significantly longer than that in group B(P=0.0001).Wound complications(P=0.02),internal haemorrhage(P=0.05),pancreatic fistula(P=0.02)and hospital mortality(P=0.0001)were significantly higher in the cirrhotic patients.Postoperative stay was significantly longer in group A(P=0.03).The median survival was 19 mo in group A and 24 mo in group B.Portal hypertension(PHT)was present in 16/67 cases of cirrhosis(23.9%).The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT(P=0.001).Postoperative morbidity(0.07)and hospital mortality(P=0.007)were higher in cirrhotic patients with PHT.CONCLUSION:Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis.PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis;therefore,it is only recommended in patients with Child A cirrhosis without portal hypertension.