Factors affecting survival after pancreaticoduodenectomy

ABSTRACT

Pancreatic cancer is the fourth most common cause of cancer related mortality in the western world. Most patients with pancreatic cancer present late in the course of the disease and have locally extensive with or without metastatic disease. Overall only up to 20% are candidates for resection and have potential for curative surgery. In the management of periampulary tumors resection is the only likelihood for cure and pancreaticoduodenectomy continues to be the surgical procedure of choice. The aim of this study was to evaluate different prognostic factors that may influence the overall survival after pancreaticoduodenectomy in patients with periampulary tumors. This retrospective study was conducted at the Gastroenterology Center, Mansowa University. The study group included 154 patients with periampulary tumor underwent pancreaticoduodenectomy in the period between September 2001 and April 2004. All patients were subjected to thorough clinical evaluation, complete laboratory work up, abdominal ultrasonography and computed tomography. Pancreaticoduodenal resection was performed as classic Whipple. All surgical specimens were histologically examined. Follow up was carried out at monthly interval during the first year then every 3 months thereafter. The study group included 154 patients, 97 [62.9%] were males and 57 [37.1%] were females with mean age of 52 +/- 11 years. Jaundice was the commonest presentation occurring in 150 patients [97.4%] .followed by abdominal pain in 118 patients [76.6%] and weight loss in 45 patients [29.2%]. Many parameters were evaluated by unvaried analysis to determine their impact on survival. The 3- year survival was 62.2% for patients below 50 year and 43.3%for those above 60 years [P= 0.02]. The 3- year survival was 46.8%for males and 48.4% for females [P=0.32]. As regard the site of origin of the tumor survival was 44.1% in pancreatic, 57.5% in ampulary, 70% in distal CBD and 60% in duodenal tumors [P = 0.02]. The survival rate was 75%for tumors less than 2 cm and 36.8% for tumors more than 3 cm [P = 0.02]. Well differentiated tumors showed a survival rate of 55.5%, whereas moderately and poorly differentiated tumors showed survival rate of 43.4% and 25% respectively [P=0.02]. Patients with stage I disease had a 3- year survival rate of 59.3% while those with stage II and III disease had a survival of 42.1% and 30% respectively [p=0.001]. The 3-year survival for patients with negative lymph nodes was 53.8% compared to 15.2% for those with positive lymph nodes [P = 0.011]. The 3- year survival was 52.8% for those with negative safety margin and as low as 10% for those with positive safety margin [P = 0.009]. Patients who received 3 units of blood transfusion or less showed a better [49.2%] survival compared to those who received more than 3 units [36.3%], a result which was statistically significant [P=0.029]. Periampulary carcinoma represents a major therapeutic challenge to surgeons. Despite recent improvement in hospital mortality and morbidity, the long-term survival after pancreaticoduodenectomy is still disappointing and many factors should be considered to improve the outcome. We believe that, the age of the patient, the site of origin of the tumor, the cellular differentiation, the pathological tumor stage, the resection margin and the amount of blood transfusion all are important prognostic factors and should be considered in selecting patients eligible to surgical resection