Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma - Comparison of morbidity and mortality and short-term outcome

Objective This prospective, randomized, single-institution trial was design ed to evaluate the end points of mortality, morbidity, and survival in pati ents undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy). Summary Background Data Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphad enectomy in association with a pancreaticoduodenal resection may improve lo ng-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticiz ed for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers. Methods Between April 1996 and December 1997, 114 patients with periampulla ry adenocarcinoma were enrolled in an ongoing, prospective, randomized tria l at The Johns Hopkins Hospital. After intraoperative verification of compl etely resected periampullery adenocarcinoma, the patients were randomized t o receive either a standard pancreaticoduodenectomy (removing only the peri pancreatic lymph nodes en bloc with the specimen) or a radical pancreaticod uodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. T he postoperative morbidity, mortality, and short-term outcomes were examine d. Results Of the 114 patients randomized, 56 underwent a standard pancreatico duodenectomy and 58 a radical pancreaticoduo-denectomy. The two groups were statistically similar with regard to age and gender, but there was a highe r percentage of white patients in the radical group. All the patients in th e radical group underwent distal gastric resection, whereas 86% of the pati ents in the standard group underwent pylorus preservation. The mean operati ve time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two group s with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and t wo in the radical group. The complication rates were 34% for the standard g roup and 40% for the radical group. Patients undergoing radical resection h ad a higher incidence of early delayed gas tric emptying but had similar ra tes of other complications, such as pancreatic fistula, wound infection, in traabdominal abscess, and need for reoperation. The mean total number of ly mph nodes resected was higher in the radical group. Of the 58 patients in t he radical group, only 10% had metastatic carcinoma in the resected retrope ritoneal lymph nodes, and none of those patients had the retroperitoneal no des as the only site of lymph node involvement. The 1-year actuarial surviv al rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group. Conclusions These data demonstrate that radical pancreaticoduodenectomy (wi th the addition of a distal gastrectomy and extended retroperitoneal lympha denectomy to a standard pancreaticoduodenectomy) can be performed with simi lar morbidity and mortality to standard pancreaticoduodenectomy. However, t he survival data are not sufficiently mature and the numbers of patients en rolled are not adequate to allow firm conclusions to be drawn regarding sur vival benefit.