650 CONSECUTIVE PANCREATICODUODENECTOMIES IN THE 1990S - PATHOLOGY, COMPLICATIONS, AND OUTCOMES

Objective The authors reviewed the pathology, complications, and outco mes in a consecutive group of 650 patients undergoing pancreaticoduode nectomy in the 1990s. Summary Background Data Pancreaticoduodenectomy has been used increasingly in recent years to resect a variety of mali gnant and benign diseases of the pancreas and periampullary region. Me thods Between January 1990 and July 1996, inclusive, 650 patients unde rwent pancreaticoduodenal resection at The Johns Hopkins Hospital. Dat a were recorded prospectively on ail patients. All pathology specimens were reviewed and categorized. Statistical analyses were performed us ing both univariate and multivariate models. Results The patients had a mean age of 63 +/- 12.8 years, with 54% male and 91% white. The numb er of resections per year rose from 60 in 1990 to 161 in 1995. Patholo gic examination results showed pancreatic cancer (n = 282; 43%), ampul lary cancer (n = 70; 11%), distal common bile duct cancer (n = 65; 10% ), duodenal cancer (n = 26; 4%), chronic pancreatitis (n = 71; 11%), n euroendocrine tumor (n = 31; 5%), periampullary adenoma (n = 21; 3%), cystadenocarcinoma (n = 14; 2%), cystadenoma (n = 25; 4%), and other ( n = 45; 7%). The surgical procedure involved pylorus preservation in 8 2%, partial pancreatectomy in 95%, and portal or superior mesenteric v enous resection in 4%. Pancreatic-enteric reconstruction, when appropr iate, was via pancreaticojejunostomy in 71% and pancreaticogastrostomy in 29%. The median intraoperative blood loss was 625; mL, median unit s of red cells transfused was zero, and the median operative time was 7 hours. During this period, 190 consecutive pancreaticoduodenectomies were performed without a mortality. Nine deaths occurred in-hospital or within 30 days of operation (1.4% operative mortality). The postope rative complication rate was 41%, with the most common complications b eing early delayed gastric emptying (19%), pancreatic fistula (14%), a nd wound infection (10%). Twenty-three patients required reoperation i n the immediate postoperative period (3.5%), most commonly for bleedin g, abscess, or dehiscence. The median postoperative length of stay was 13 days. A multivariate analysis of the 443 patients with periampulla ry adenocarcinoma indicated that the most powerful independent predict ors favoring long-term survival included a pathologic diagnosis of duo denal adenocarcinoma, tumor diameter <3 cm, negative resection margins , absence of lymph node metastases, well-differentiated histology, and no reoperation. Conclusions This single institution, high-volume expe rience indicates that pancreaticoduodenectomy can be performed safely for a variety of malignant and benign disorders of the pancreas and pe riampullary region. Overall survival is determined largely by the path ology within the resection specimen.