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©The Author(s) 2017.
World J Gastroenterol. Oct 14, 2017; 23(38): 7025-7036
Published online Oct 14, 2017. doi: 10.3748/wjg.v23.i38.7025
Published online Oct 14, 2017. doi: 10.3748/wjg.v23.i38.7025
Table 1 Demographic and preoperative data
Variable | Total,n = 1000 | First 10 yr,1993-2002 | Second 10 yr,2003-2012 | Last 5 yr,2013-2017 | P-value |
Age in yr | 54 (12-88) | 53 | 55 | 55 | 0.22 |
Sex | |||||
Male | 614 (61.4) | 190 (63.3) | 260 (58.8) | 164 (63.6) | 0.33 |
Female | 386 (38.6) | 110 (36.7) | 182 (41.2) | 94 (36.4) | |
DM | 145 (14.5) | 39 (13) | 60 (13.6) | 46 (17.8) | 0.21 |
BMI in kg/m2 | |||||
< 25 | 723 (72.3) | 250 (38.3) | 326 (73.8) | 147 (57) | 0.0001 |
> 25 | 277 (27.7) | 50 (16.7) | 116 (26.2) | 111 (43) | |
Abdominal pain | 753 (75.3) | 230 (76.7) | 329 (74.4) | 194 (74.2) | 0.12 |
Jaundice | 909 (90.9) | 265 (88.3) | 406 (91.9) | 238 (92.2 | 0.18 |
Preoperative biliary drainage | 511 (51.1) | 163 (54.5) | 226 (51.1) | 122 (47.3) | 0.23 |
Preoperative serum albumin in mg | 4 (3.2-5.2) | 4.1 | 4 | 3.9 | 0.23 |
Preoperative serum bilirubin in mg | 4 (0.5-38) | 3.1 | 4.7 | 4.3 | 0.0001 |
Preoperative CEA | 6.4 (0.5-394) | 8 | 8 | 6 | 0.09 |
Preoperative CA19-9 | 27 (0.5-1200) | 32 | 33 | 34 | 0.12 |
Table 2 Operative data
Variable | Total, n = 1000 | First 10 yr, 1993-2002 | Second 10 yr, 2003-2012 | Last 5 yr, 2013-2017 | P-value |
Cirrhosis | 129 (12.9) | 28 (9.3) | 62 (14) | 39 (15.1) | 0.009 |
Mass size in cm | 3 (0.5-15) | 3 | 3 | 3 | |
< 2 | 418 (41.8) | 123 (41) | 174 (39.4) | 123 (46.9) | 0.14 |
> 2 | 582 (58.2) | 177 (59) | 268 (60.6) | 137 (53.1) | |
Pancreatic texture | |||||
Soft | 596 (59.6) | 190 (63.3) | 263 (59.5) | 143 (55.4) | 0.23 |
Firm | 404 (40.4) | 110 (36.7) | 179 (40.5) | 115 (44.6) | |
Median pancreatic duct diameter in mm | 5 (1-15) | 0.47 | |||
< 3 | 313 (31.3) | 97(32.3) | 137 (30.9) | 79 (30.6) | |
> 3 | 687 (68.7) | 20367.7) | 305 (60.1) | 179 (69.4) | |
Pancreatic duct to posterior border in mm | 0.45 | ||||
< 3 | 421 (42.1) | 128 (42.7) | 185 (41.9) | 108 (41.9) | |
> 3 | 579 (57.9) | 172 (57.3) | 257 (58.1) | 150 (58.1) | |
Pancreatic stump mobilization in cm | 2 (1-4) | 2 | 2 | 2 | 0.45 |
CBD diameter in mm | 15 (5-30) | 15 | 15 | 15 | 0.06 |
Type of reconstruction | |||||
PG | 791 (79.1) | 235 (78.3) | 417 (94.3) | 139 (53.9) | 0.0001 |
Simple PJ | 163 (16.3) | 65 (21.7) | 25 (5.7) | 73 (28.3) | |
Isolated loop PJ | 46 (4.6) | 0 | 0 | 46 (17.8) | |
Duct to mucosa | 134 (13.4) | 9 (3) | 65 (14.7) | 60 (23.3) | |
Invaginated type with duct to mucosa | 644 (64.4) | 234 (78) | 250 (65.6) | 160 (62) | 0.0001 |
Invaginated type without duct to mucosa | 221 (22.1) | 57 (19) | 126 (28.5) | 38 (14.7) | |
No anastomosis | 1 (0.1) | 0 | 1 (0.2) | 0 | |
Standard approach | 908 (90.8) | 277 (92.3) | 388 (87.8) | 243 (94.7) | 0.004 |
Posterior approach | 92 (9.2) | 23 (7.7) | 54 (12.2) | 15 (5.8) | |
Complete meso-pancreatectomy | 574 (57.4) | 83 (27.7) | 233 (52.7) | 258 (100) | 0.0001 |
Laparoscopic assisted PD | 11 (1.1) | 0 | 0 | 11 (4.3) | 0.0001 |
Complete laparoscopic PD | 10 (1) | 0 | 0 | 10 (3.9) | |
Vascular resection | 12 (1.2) | 0 | 4 (0.9) | 8 (3.1) | 0.003 |
Primary anastomosis | 0 | 0 | 3 (0.7) | 8 (3.1) | |
Gortex | 0 | 0 | 1 (0.2) | 0 | |
Operative time in h | 5 (3.5-10) | 6 | 5 | 5 | 0.001 |
Blood loss in cc | 500 (50-4000) | 500 | 400 | 300 | 0.001 |
Table 3 Postoperative data
Variable | Total,n = 1000 | First 10 yr,1993-2002 | Second 10 yr,2003-2012 | Last 5 yr,2013-2017 | P-value |
Hospital stay in d | 8 (5-71) | 9 | 8 | 8 | 0.0001 |
Time to oral intake in d | 5 (4-56) | 6 | 5 | 5 | 0.33 |
Total amount of drainage in mL | 700 (40-35000) | 1200 | 600 | 600 | 0.0001 |
Drain removal in d | 8 (4-71) | 8 | 8 | 8 | 0.03 |
Total postoperative complications | 323 (32.3) | 120 (40) | 131 (29.6) | 72 (27.9) | 0.02 |
Dindo grade | |||||
I | 114 (11.4) | 24 | 47 | 43 | |
II | 97 (9.7) | 40 | 45 | 12 | 0.11 |
III | 69 (6.9) | 36 | 24 | 9 | |
IV and V | 43 (4.3) | 20 | 15 | 8 | |
Severe complications, ≥ III | |||||
Minor | 211 (21.1) | 84 | 92 | 55 | 0.23 |
Major | 109 (10.9) | 56 | 69 | 17 | |
Pancreatic fistula | 139 (13.9) | 45 (15) | 56 (12.7) | 38 (14.7) | 0.01 |
Grade A | 67 (6.7) | 14 | 33 | 20 | 0.04 |
Grade B | 48 (4.8) | 20 | 17 | 11 | |
Grade C | 24 (2.4) | 11 | 6 | 7 | |
DGE | 180 (18) | 76 (25.3) | 67 (15.2) | 37 (14.3) | 0.06 |
Types of DGE | |||||
Secondary DGE | 152 (15.2) | 70 (23.3) | 54 (12.2) | 27 (10.5) | 0.03 |
Primary DGE | 28 (2.8) | 5 (1.7) | 13 (2.9) | 10 (3.9) | |
Pulmonary complications | 46 (4.6) | 20 (6.7) | 21 (4.8) | 5 (1.6) | 0.01 |
Bile leak | 73 (7.3) | 39 (13) | 19 (4.3) | 15 (5.8) | 0.001 |
Postoperative bleeding | 25 (2.5) | 13 (4.3) | 7 (1.6) | 5 (1.9) | 0.49 |
Pancreatitis | 20 (2) | 12 (4.3) | 7 (1.6) | 1 (0.4) | 0.004 |
Bleeding PG | 15 (1.5) | 8 (2.7) | 5 (1.2) | 2 (0.8) | 0.14 |
Wound infection | 50 (5) | 13 (4.6) | 25 (5.7) | 12 (4.7) | 0.77 |
Re-operation | 74 (7.4) | 25 (8.3) | 33 (7.5) | 16 (6.2) | 0.21 |
Recurrence | 321 (36.9) | 130 (50.4) | 125 (32.6) | 66 (28.7) | 0.0001 |
Hospital mortality | 43 (4.3) | 20 (6.6%) | 15 (3.4) | 8 (3.1) | 0.02 |
Postoperative chemoradiotherapy | 275 (27.5) | 0 | 132 (29.9) | 143 (55.4) | 0.0001 |
Overall median survival in mo | 26 (1-300) | 21 | 30 | 37 | 0.0001 |
1 yr | 90% | 87% | 93% | 87% | |
3 yr | 33% | 19% | 37% | 64% | |
5 yr | 19% | 11% | 21% |
Table 4 Univariate and multivariate analyses of risk factors of development of post-operative pancreatic fistula
Univariate | Multivariate | Exp(B) | 95%CI for Exp(B) | ||
P-value | P-value | Lower | Upper | ||
Age grouping > 60 yr | 0.2 | ||||
Sex | 0.99 | ||||
DM | 0.58 | ||||
BMI >25 kg/m2 | 0.0001 | 0.0001 | 6.468 | 4.193 | 9.977 |
Preoperative serum bilirubin > 10 mg% | 0.62 | ||||
Preoperative ERCP | 0.52 | ||||
Liver cirrhosis | 0.05 | 0.328 | 0.699 | 0.341 | 1.434 |
Size of the tumor > 2 cm | 0.91 | ||||
Soft pancreas | 0.0001 | 0.0001 | 0.218 | 0.14 | 0.341 |
Pancreatic duct diameter > 3 mm | 0.0001 | 0.0001 | 0.182 | 0.118 | 0.279 |
Pancreatic duct closely related to posterior border of pancreas > 3 mm | 0.0001 | 0.0001 | 0.372 | 0.243 | 0.57 |
Blood loss > 1000 mL | 0.67 | ||||
Blood transfusion | 0.94 | ||||
Type of pancreatic reconstruction | 0.62 | ||||
Duration of operation | 0.75 | ||||
Site of the tumor | 0.34 | ||||
Period of the study | 0.001 | 0.001 | 0.615 | 0.461 | 0.82 |
Table 5 Postoperative pathology n (%)
Variable | Total,n = 1000 | First 10 yr,1993-2002 | Second 10 yr,2003-2012 | Last 5 yr,2013-2017 | |
Site of the tumor | |||||
Ampullary tumor | 312 (31.2) | 92 (30.7) | 145 (32.8) | 75 (29) | |
Pancreatic head mass | 556 (55.6) | 171 (57) | 257 (58.1) | 128 (49.6) | 0.0001 |
CBD duct tumor | 41 (4.1) | 16 (5.3) | 13 (2.9) | 12 (4.7) | |
Duodenal tumor | 61 (6.1) | 20 (6.7) | 27 (6.1) | 14 (5.4) | |
Uncinate process mass | 30 (3) | 1 (0.3) | 0 | 29 (11.3) | |
Pathological diagnosis | |||||
Adenocarcinoma | 836 (83.6) | 250 (83.3) | 357 (80.7) | 229 (88.8) | |
Undifferentiated carcinoma | 20 (2) | 1 (1.7) | 19 (4.3) | 0 | |
Papillary cystadenocarcinoma | 6 (0.6) | 4 (1.3) | 2 (0.5) | 0 | 0.0001 |
Lymphoma | 4 (0.4) | 2 (0.6) | 2 (0.5) | 0 | |
Neuroendocrine tumor | 28 (2.8) | 12 (4) | 10 (2.3) | 6 (2.3) | |
Solid pseudopapillary tumor | 20 (2) | 5 (1.7) | 8 (1.8) | 7 (2.7) | |
Chronic pancreatitis | 24 (2.4) | 6 (2) | 14 (3.2) | 4 (1.6) | |
Benign cyst | 12 (1.2) | 3 (1) | 8 (1.8) | 1 (0.4) | |
Adenoma with dysplasia | 41 (4.1) | 15 (5) | 19 (4.3) | 7 (2.7) | |
Gastrointestinal stromal tumor | 2 (0.2) | 0 | 1 (0.2) | 1 (0.4) | |
Glomus | 1 (0.1) | 1 (0.3) | 0 | 0 | |
Adenosquamous | 2 (0.2) | 1 (0.3) | 1 (0.2) | 0 | |
Pleomorphic adenoma | 1 (0.1) | 0 | 1(0.2) | 0 | |
Adenomyoma | 3 (0.3) | 0 | 0 | 3 (1.2) | |
Malignant | 870 (87) | 258 (86) | 382 (86.4) | 230 (89.1) | 0.38 |
Borderline | 48 (4.8) | 17(5.7) | 18 (4.1) | 13 (5.1) | |
benign | 82 (8.2) | 25 (8.3) | 42 (9.5) | 15 (5.8) | |
Number of dissected lymph node | 6 (0-40) | 5 (0-18) | 6 (0-40) | 6 (0-40) | 0.59 |
Number of lymph node infiltration | 0 (0-14) | 0 (0-3) | 0 (0-14) | 0 (0-14) | 0.07 |
Perineural infiltration | 187 (18.7) | 62 (20.7) | 75 (17) | 50 (19.9) | 0.09 |
Perivascular infiltration | 134 (134) | 40 (13.3) | 66 (14.9) | 28 (10.9) | 0.13 |
Pancreatic safety margin | |||||
R1 | 91 (9.1) | 40 (13.3) | 41 (9.3) | 10 (3.8) | 0.01 |
R2 | 15 (1.5) | 7 (2.3) | 6 (1.4) | 2 (0.7) |
- Citation: El Nakeeb A, Askar W, Atef E, Hanafy EE, Sultan AM, Salah T, shehta A, Sorogy ME, Hamdy E, Hemly ME, El-Geidi AA, Kandil T, Shobari ME, Allah TA, Fouad A, Zeid MA, Eneen AAE, El-Hak NG, Ebidy GE, Fathy O, Sultan A, Wahab MA. Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases. World J Gastroenterol 2017; 23(38): 7025-7036
- URL: https://www.wjgnet.com/1007-9327/full/v23/i38/7025.htm
- DOI: https://dx.doi.org/10.3748/wjg.v23.i38.7025