ABSTRACT
Objective:To study the value of metastatic positivety in lymph nodes group 8a in deciding on extended lymph node dissection in pancreaticoduodenectomy(PD) for pancreatic head cancer.Methods:A retrospective study on 165 patients with pancreatic head cancer treated with PD at the Department of Pancreas and Spleen Surgery, Hepatobiliary Hospital of Hunan Provincial People's Hospital between January 2014 to June 2019 was performed. There were 101 males and 64 females with ages ranging from 38 to 75 (median 57) years. Patients who underwent standard lymph node dissection were included in the standard group ( n=88), and extended lymph node dissection in the extended group ( n=77). These patients were further divided into 4 subgroup. Subgroup A (standard PD in patients with negative nodes in group 8a, n=61), Subgroup B (extended PD in patients with negative nodes in group 8a, n=47), Subgroup C (standard PD in patients with positive nodes in group 8a, n=27), and Subgroup D (extended PD in patients with positive nodes in group 8a, n=30). The operation time, intraoperative blood loss, postoperative survival rates, complications were compared among the groups and subgroups. Results:The operation time and intraoperative blood loss of the standard group were (456.8±30.4) min and (264.28±101.14) ml, respectively, which were significantly lower than the extended group of (507.1±45.7) min and (388.9±155.3) ml (all P<0.05). The incidence of postoperative complications in the extended group (31.2%, 24/77) was significantly higher than that in the standard group (14.8%, 13/88) ( P<0.05). When compared with subgroup B, the cumulative survival rate of patients in subgroup A was not significantly different ( P>0.05). However, the cumulative survival rate of patients in subgroup C was significantly lower than that in subgroup D ( P<0.05). The cumulative survival rate of subgroup A was also significantly better than that of subgroup C ( P<0.05). There was no significant difference in the cumulative survival rates between group B and group D ( P>0.05). Conclusions:PD with extended lymph node dissection improved the survival rates in patients with cancer of the head of the pancreas with positive lymph nodes in group 8a. For these patients, extended lymph node dissection is recommended. With negative lymph nodes in group 8a, standard lymph node dissection is recommended.
ABSTRACT
Objective:To investigate the classification and surgical management of chronic calcifying pancreatitis.Methods:The retrospective and descriptive study was conducted. The clinical data of 121 patients with chronic calcifying pancreatitis who were admitted to Hunan Provincial People′s Hospital from January 2015 to December 2019 were collected. There were 99 males and 22 females, aged from 10 to 78 years, with a median age of 43 years. The patients with type Ⅰ chronic calcifying pancreatitis underwent pancreaticoduodenectomy, duodenum-preserving pancreatic head total resection, or duodenum-preserving pancreatic head spoon-type resection respectively, and external drainage when combined with peripancreatic pseudocyst. Patients with type Ⅱ chronic calcifying pancreatitis underwent resection of pancreatic body and tail combined with splenectomy or dissection of pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis. Patients with type Ⅲ chronic calcifying pancreatitis underwent pancreaticoduodenectomy or duodenum-preserving pancreatic head spoon-type resection, and external drainage when combined with peripancreatic pseudocyst. Patients with type Ⅳ chronic calcifying pancreatitis underwent basin-type internal drainage. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect the recurrence of pain or chronic pancreatitis, the data of blood glucose, the morbidity of diabetes and diarrhea after surgery up to January 2020. Measurement data with normal distribution were represented as Mean± SD and measurement data with skewed distribution were described as M (range). Count data were represented as absolute numbers. Results:(1) Surgical situations: of the 48 patients with type Ⅰ chronic calcifying pancreatitis, 15 patients underwent pancreaticoduodenectomy with the operation time of (6.8±1.9)hours and volume of intraoperative blood loss of (398±110)mL, 8 patients underwent duodenum-preserving pancreatic head total resection due to no dilation of pancreatic duct with the operation time of (3.7±0.8)hours and volume of intraoperative blood loss of (137±62)mL, 25 patients underwent duodenum-preserving pancreatic head spoon-type resection due to dilation of pancreatic duct with the operation time of (3.9±1.5)hours and volume of intraoperative blood loss of (123±58)mL. Of the 8 patients with type Ⅱchronic calcifying pancreatitis, 2 patients underwent resection of pancreatic body and tail combined with splenectomy with an average operation time of 5.1 hours and an average volume of intraoperative blood loss of 200 mL, 6 patients underwent dissection of pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis with the operation time of (2.7±0.8)hours and volume of intraoperative blood loss of (145±39)mL. Of the 49 patients with type Ⅲ chronic calcifying pancreatitis, 4 patients were underwent pancreaticoduodenectomy with the operation time of (7.2±1.4)hours and volume of intraoperative blood loss of (415±98)mL, 45 patients underwent duodenum-preserving pancreatic head spoon-type resection due to dilation of pancreatic duct with the operation time of (4.3±1.1)hours and volume of intraoperative blood loss of (135±47)mL. Sixteen patients with type Ⅳ chronic calcifying pancreatitis underwent basin-type internal drainage with the operation time of (3.3±1.3)hours and volume of intraoperative blood loss of (150±27)mL. (2) Postoperative situations: 15 of the 48 patients with type Ⅰ chronic calcifying pancreatitis who underwent pancreaticoduodenectomy had the time to first anal flatus of (2.9±1.1)days, time to initial fluid diet intake of (3.5±1.1)days, and duration of hospital stay of (14.8±2.7)days, respectively. Of the 3 patients who had postoperative complications, 2 had gastrointestinal hemorrhage (1 case was cured after hemostasis under gastroscope and the other was cured after interventional therapy), 1 with grade A pancreatic fistula was cured after delaying the time of extubation, no biliary fistula occurred. Eight patients undergoing duodenum-preserving pancreatic head total resection had the time to first anal flatus of (2.0±0.5)days, time to initial fluid diet intake of (2.5±0.4)days, and duration of hospital stay of (9.5±2.5)days, respectively. One case with postoperative grade A pancreatic fistula was cured after delaying the time of extubation. Twenty-five patients undergoing duodenum-preserving pancreatic head spoon-type resection had the time to first anal flatus of (2.4±0.8)days, time to initial fluid diet intake of (2.5±1.3)days, and duration of hospital stay of (9.8±3.1)days, respectively. One case with postoperative gastrointestinal hemorrhage was cured after interventional therapy and 1 case with grade A pancreatic fistula was cured after delaying the time of extubation. Two of the 8 patients with type Ⅱ chronic calcifying pancreatitis who underwent resection of pancreatic body and tail combined with splenectomy had an average time to first anal flatus of 3.0 days, an average time to initial fluid diet intake of 3.5 days, and an average duration of hospital stay of 14.0 days, respectively.There was no complication during perioperative period. Six of the 8 patients with type Ⅱ chronic calcifying pancreatitis who underwent dissection of the pancreatic duct combined with pancerato-jejunum Roux-en-Y anastomosis had the time to first anal flatus of (2.5±0.5)days, time to initial fluid diet intake of (2.5±0.7)days, and duration of hospital stay of (8.5±1.5)days, respectively. Two cases with postoperative grade A pancreatic fistula were cured after delaying the time of extubation. Four of the 49 patients with type Ⅲ pancreatic duct stone who underwent pancreaticoduodenectomy had the time to first anal flatus of (3.2±0.8)days, time to initial fluid diet intake of (4.1±1.2)days, and duration of hospital stay of (15.3±2.4)days, respectively. One case with postoperative grade A pancreatic fistula was cured after delaying the time of extubation without hemorrhage or biliary fistula. Forty-five of the 49 patients with type Ⅲ chronic calcifying pancreatitis who underwent duodenum-preserving pancreatic head spoon-type resection had the time to first anal flatus of (2.5±1.6)days, time to initial fluid diet intake of (2.8±0.9)days, and duration of hospital stay of (10.1±2.8)days, respectively. One case with postoperative anastomotic bleeding was cured after reoperation. One case with grade A pancreatic fistula was cured after delaying the time of extubation and 1 case with postoperative grade B pancreatic fistula was cured after puncture-duct-douch treatment. Sixteen patients with type Ⅳ chronic calcifying pancreatitis who underwent basin-type internal drainage had the time to first anal flatus of (2.6±0.7)days, time to initial fluid diet intake of (3.3±0.5)days, and duration of hospital stay of (10.4±3.0)days respectively. One case with intraperitoneal hemorrhage which represented as small amount of dark red liquid in the drainage tube of jejunum loop was cured after puncture-duct-douch treatment with noradrenaline sodium chloride solution. (3) Follow-up: Of the 121 patients, 113 (44 of type Ⅰ, 7 of type Ⅱ, 46 of type Ⅲ, 16 of type Ⅳ) were followed up for 3-58 months, with an average time of 34 months. During the follow-up, 13 patients (5 of type Ⅰ, 1 of type Ⅱ, 6 of type Ⅲ, 1 of type Ⅳ) had the recurrence of pain or pancreatitis, 55 patients (15 of type Ⅰ, 40 of type Ⅲ) with abdominal pain were improved significantly, and 45 patients (24 of type Ⅰ, 6 of type Ⅱ, 15 of type Ⅳ) did not have abdominal pain. Of the 37 patients (13 of type Ⅰ, 2 of type Ⅱ, 17 of type Ⅲ, 5 of type Ⅳ) with diabetes , 20 (6 of type Ⅰ, 2 of type Ⅱ, 12 of type Ⅲ) had blood glucose returned to normal and 17 (7 of type Ⅰ, 5 of type Ⅲ, 5 of type Ⅳ) needed controlling blood sugar with medicine. There were 5 patients (4 of type Ⅰ, 1 of type Ⅲ) diagnosed with diabetes and 3 patients (1 of type Ⅱ, 2 of type Ⅲ) with diarrhea postoperatively. Two patients of type Ⅲ chronic calcifying pancreatitis died, including 1 died of pancreatic cancer at 18 months after pancreaticoduodenectomy and 1 died of severe acute pancreatitis at 5 months after duodenum-preserving pancreatic head spoon-type resection.Conclusions:Chronic calcifying pancreatitis is a benign disease and should be treated to preserve functional tissues. Different surgical procedures should be adopted to treat different types of calcifying pancreatitis.