Abstract: Objective:To explore the application value of a new classification of the pancreatic head cancer based on relationship between pancreatic head cancer and adjacent vessels evaluated by computed tomography in the surgical procedures and prognosis of patients.
Methods:The clinical data of 127 patients with pancreatic head cancer who were admitted to the Tongji Hospital of Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. According to the relationship between tumor and blood vessels by preoperative multislice spiral computed tomography (MSCT), all patients were divided into four types, including type Ⅰ, type Ⅱ, type Ⅲ and type Ⅳ. The different surgical approaches and procedures were performed based on the location of tumors and a new classification of pancreatic head cancer. After operation, patients received the unobstructed peritoneal drainage and regular supporting treatment such as monitoring of vital signs, fasting and water, fluid infusion, nutritional support and antibiotics administration. The data of postoperative complications were collected according to principle of International Study Group on Pancreatic Surgery (ISGPS). The preoperative conditions of patients were observed and recorded, including sex, age, body mass index, jaundice, abdominal pain, other symptoms of digestive tract, recent weight loss and diabetes mellitus. The intraoperative and postoperative conditions were analyzed, including surgical method, operation time, volume of blood loss, postoperative complications, duration of postoperative hospital stay and pathological examination. All the patients were followed up by outpatient examination and telephone interview at postoperative month 1, 3, 6, 12, 18 up to December 2014. Measurement data with normal distribution were presented as  ±s. Comparisons among groups were evaluated with the oneway ANOVA and Wilcoxon rank sum test. Nonnormal distribution data were described as M (range).  Count data were analyzed with chisquare test. Survival curve was drawn by the KaplanMeier method, and survival rate was analyzed using the Logrank test.
Results (1)The classification of pancreatic head cancer: type Ⅰ, type Ⅱ, type Ⅲ and type Ⅳ were detected respectively in 83, 20, 11 and 13 patients. The jaundice and abdominal pain of patients with type Ⅰ, type Ⅱ, type Ⅲ and type Ⅳ were occurred in 31, 9, 0, 2 and 23, 8, 7, 7 patients, respectively, with a significant difference (χ²= 5.63, 3.49, P<0.05). (2)The intraoperative situation: 80 patients underwent pancreaticoduodenectomy (PD) with “vein first” approach, including 74 of type Ⅰ and 6 of type Ⅱ. Fortyseven patients underwent PD combined with resection of portal vein and superior mesenteric vein, including 9 patients with type Ⅰ, 14 patients with type Ⅱ, 11 patients with type Ⅲ and 13 patients with type Ⅳ. Thirteen patients received extended lymph node dissection, including 2 patients with type Ⅰ, 3 patients with type Ⅱ, 4 patients with type Ⅲ and 4 patients with type Ⅳ. The methods of digestive reconstruction: of 74 patients receiving pancreaticgastric anastomosis, type Ⅰ, Ⅱ, Ⅲ and Ⅳ were detected respectively in 52, 10, 6 and 6 patients. Of 37 patients receiving PD, type Ⅰ, Ⅱ, Ⅲ and Ⅳ were detected respectively in 22, 6, 5 and 4 patients. Of 16 patients receiving pancreaticojejunal anastomosis, type Ⅰ, Ⅱ and Ⅳ were detected respectively in 9, 4 and 3 patients. The operation time and volume of blood loss in patients with type Ⅰ, Ⅱ, Ⅲ and Ⅳ were (287±47)minutes, (354±64)minutes, (342±86)minutes, (380±46)minutes and (399±180)mL, (480±233)mL, (418±256)mL, (554±307)mL, respectively, with significant differences (F=4.02, 3.91, P<0.05). (3)The postoperative situation: the duration of hospital stay in patients with type Ⅰ, Ⅱ, Ⅲ and Ⅳ were (22±10)days, (29±10)days, (28±12)days and (33±17)days, respectively, showing significant differences (F=4.01, P<0.05). (4)The results of pathological examination: tumor diameter in patients with type Ⅰ, Ⅱ, Ⅲ and Ⅳ were respectively (3.3±1.1)cm, (4.1±0.9)cm, (4.1±1.0)cm and (4.6±1.1)cm, T1-2 stage, T3-4 stage and nerve invasion were detected in 59, 24 and 14 cases with type Ⅰ, 0, 20 and 8 cases with type Ⅱ, 0, 11 and 6 cases with type Ⅲ, 0, 13 and 9 cases with type Ⅳ, respectively, showing significant differences (F=5.12, χ²=58.41, 20.76, P<0.05). (5)The results of followup: 112 patients were followed up (74 with type Ⅰ, 18 with type Ⅱ, 9 with type Ⅲ and 11 with type Ⅳ) and 15 patients lost to followup. The mean survival time and 2year survival rate were 24 months (range, ²- 60 months) and 42.2% in patients with type Ⅰ, 16 months (range, 2-30 months) and 25.0% in patients with type Ⅱ, 18 months (range, ²-30 months) and 27.3% in patients with type Ⅲ and 16 months (range, 2- 26 months) and 15.0% in patients with type Ⅳ, showing a significant difference in the survival of patients (χ²=16.85, P<0.05). The survival of patients with type Ⅰ was significantly different from that of patients with type Ⅱ, Ⅲ and Ⅳ (χ²=12.11, 5.10, 10.73, P<0.05). 〖HQK〗There were no significant differences in the survival between patients with type Ⅱ and type Ⅲ, type Ⅳ (χ²=0.22, 0.48, P>0.05). There was no significant difference in the survival of patients between type Ⅲ and type Ⅳ (χ²=1.09, P>0.05).
Conclusion:A new classification of pancreatic head cancer based on the relationship between tumor and adjacent vessels may play an important role in selecting appropriate surgical procedure and predicting the prognosis.