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Clinical Observations

Comparative analysis of duodenum-preserving pancreatic head resection and pancreaticoduodenectomy

Sun, Yong-Hui1; Ding, Nan2; Cheng, Kun1; Lin, Hai1; Xu, Jia-Qi1; Chen, Qi-Long1

Editor(s): Shi, Qiang

Author Information
doi: 10.1097/CM9.0000000000000968

There is controversy regarding the perioperative complications, safety, and long-term quality of life for duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD). We performed a comparative analysis of DPPHR and PD in the treatment of benign and low-grade malignant diseases of the pancreatic head. The study was approved by the Institutional Review Board of the Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University (No. K202001-14), and was in accordance with the Declaration of Helsinki. Because this was a retrospective study and the data analysis was performed anonymously, this study was exempt from informed consent from patients.

Ninety-nine patients (≥18 years of age) who underwent DPPHR or PD in the First Affiliated Hospital of Xinjiang Medical University between January 2014 and December 2018 were initially included. During the follow-up period, five patients in the DPPHR group and eight patients in the PD group were lost to follow-up. Ultimately, 86 patients were included in our study. The inclusion criteria were: (1) post-operative pathology results that suggested a diagnosis of chronic pancreatitis, benign diseases or low-grade malignancy of the head of pancreas; (2) complete medical records; (3) absence of other serious medical diseases or other malignant tumors. The exclusion criteria were: (1) a history of other tumors; (2) post-operative pathology results that suggested a diagnosis of medium- or high-grade malignancy; (3) previous surgical treatment for pancreatic diseases; (4) incomplete clinical data; (5) general worsening of the patient's condition. Benign diseases of the pancreatic head include chronic pancreatitis, pancreatic pseudocysts, serous cystic neoplasm, pancreatic trauma, and pancreas divisum. Low-grade malignant diseases of the pancreatic head include mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, solid-pseudopapillary tumor of pancreas, and pancreatic neuroendocrine tumors.

This was a retrospective cohort study. The patients were divided into two groups based on the treatment they received: the DPPHR group (n = 29) or the PD group (n = 57). Uniform training for all researchers was provided using standardized procedures. Follow-up was performed on an outpatient basis and included various examinations such as computed tomography, magnetic resonance imaging, and B-mode ultrasound 3 months after surgery. We checked the outpatient medical records and telephone or mail inquiries of all patients until December 31, 2019.

Detailed information on the surgical procedures is described elsewhere.[1–5] PD consisted of the complete removal of the pancreatic head and uncinate process with the cut margin above the superior mesenteric vein, the duodenum, the partial stomach, and the common bile duct. Reconstruction was accomplished by pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy. All modifications of DPPHR (Beger, Berne, and Frey) were permissible in this study. For the Beger modification, the pancreas was transected above the superior mesenteric-portal vein followed by excavation of the pancreatic head and preservation of a small rim (0.5–0.8 mm) of pancreatic head tissue along with the duodenum. Reconstruction was accomplished by pancreaticojejunostomy.[2] The residual pancreatic tissue along the duodenum was anastomosed with the jejunal loop or stitched. For the Berne modification, local excision of the tumor in the head of the pancreas was performed, without division and cutting of the pancreas over the portal vein. Reconstruction was accomplished by a single side-to-side pancreaticojejunostomy.[5] For the Frey modification, a limited resection of the pancreatic head was performed with extended drainage of the main pancreatic duct by longitudinal pancreatectomy of the body and tail of the pancreas. Reconstruction was performed with a Roux-en-Y loop with side-to-side pancreaticojejunostomy.[4]

General data were collected including age, sex, body mass index, smoking habits, drinking habits, comorbid conditions (hypertension, diabetes), and occurrence of specific symptoms (jaundice, pain, nausea, and vomiting). The patients were followed for a long time (≥1 year), their quality of life was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (QLQ-C30) (version 3.0),[6,7] and their nutritional status was evaluated using the Nutrition Risk Screening 2002 tool. During the entire follow-up period, data were recorded regarding the following: diarrhea, post-operative fatty liver, new-onset diabetes, bile duct stones, cholangitis, anastomotic stricture, anastomotic calculi, and exocrine dysfunction.

The QLQ-C30 scores and other measurement data were expressed by mean ± standard deviation, while data with a skewed distribution were expressed as the median (range), and independent-samples t-test or Mann-Whitney U test were used for analysis, respectively. The statistical analysis of the enumeration data was carried out by the Chi-square test or Fisher exact test. A P value < 0.05 was considered statistically significant. All statistical analyses were conducted using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA).

The diagnoses of the included patients are shown in Supplementary Table 1, http://links.lww.com/CM9/A259. Our results showed that, there was a significant difference in the operation time (493.45 ± 155.00 vs. 600.09 ± 140.72 min, P = 0.002), duration of hospital stay (24.55 ± 12.24 vs. 31.37 ± 12.38 days, P = 0.018), cost of hospitalization (94,300 ± 33,000 vs. 128,200 ± 47,500 RMB yuan, P = 0.001), post-operative pancreatic exocrine insufficiency (6.9% vs. 36.8%, P = 0.007), post-operative weight change (3.00 [0.50–6.50] vs. 0.00 [0.00–2.00] kg, P = 0.002), and cumulative long-term (⩾3 months after surgery) complications (34.5% vs. 64.9%, P = 0.007) between the DPPHR and PD groups [Table 1 and Supplementary Table 2, http://links.lww.com/CM9/A259]. For the QLQ-C30 survey at 1 year after operation, scores of the overall health status were significantly improved in the DPPHR group than in the PD group (all P < 0.05) [Supplementary Table 3, http://links.lww.com/CM9/A259].

Table 1
Table 1:
Patient characteristics and operative/post-operative data in duodenum-preserving pancreatic head resection and pancreaticoduodenectomy groups.

In conclusion, DPPHR has the advantages of short operation time, short duration of hospital stay, and low cost of hospitalization when compared with PD. Furthermore, DPPHR also has the advantages of lower incidence of post-operative complications, higher post-operative quality of life—all while achieving the same surgical outcome. In the treatment of benign and low-grade malignant diseases of the head of the pancreas, DPPHR might be better than PD.

Conflicts of interest

None.

References

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