Abstract: Objective:To investigate the clinical effects of laparoscopic pancreaticoduodenectomy (LPD) for distal cholangiocarcinoma.
Methods:The retrospective cross-sectional study was conducted. The clinicopathological data of 37 patients who underwent LPD for distal cholangiocarcinoma in the Hunan Provincial People′s Hospital between January 2013 and November 2016 were collected. LPD for distal cholangiocarcinoma was performed using the “en-block” procedure. According to the principle of “one axis, two planes and four zones”, anatomy used posterior approach, anterior approach and medial approach, lymph node dissection was performed from carotid sheath outside, and en bloc specimens were resected. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination was performed to detect the patients′ recurrence-free survival up to November 2017. Measurement data with normal distribution were represented as ±s. The survival curve and rate were drawn and calculated by the Kaplan-Meier method.
Results:(1) Surgical and postoperative recovery situations: all the 37 patients underwent successful LPD, without conversion to open surgery and perioperative death. The operation time, volume of blood loss and case with intraoperative blood transfusion were (326±55)minutes, (176±39)mL and 1, respectively. The time to initial exsufflation and time for diet intake were respectively (4.5±1.6)days and (5.3±2.7)days. Of 37 patients, 14 had postoperative complications, including 8 with pancreatic fistula (6 with biochemical fistula and 2 with grade B pancreatic fistula), 1 with biliary fistula, 3 with postoperative bleeding (2 with intra-abdominal bleeding and 1 with gastrointestinal anastomosis bleeding), 2 with delayed gastric emptying (grage A), 2 with intra-abdominal infection and 2 with pulmonary infection; the same patients can merge multiple complications. Three patients were in Clavien-Dindo classification ≥Ⅲ. One patient received reoperation and other patients were improved by symptomatic treatment. Duration of hospital stay of 37 patients was 13.5 days (range, 8.0-33.0 days). Eight patients underwent adjuvant chemotherapy of 4-6 cycles by taking orally tegafur or gemcitabine with cisplatin. (2) Postoperative pathological examination: tumor diameter and pancreatic duct diameter of 37 patients were (2.1±1.1)cm and (2.5±1.2)mm,respectively . Of 37 patients, 9, 13 and 15 were respectively detected in high-differentiated, moderate-differentiated and low-differentiated adenocarcinoma. Surgical margins: 35 patients received R0 resection and 2 received R1 resection. Number of lymph node dissected, cases with lymph node metastasis and number of positive lymph nodes were respectively 18.5±4.9, 16 and 1.7±1.4. Analysis of lymph node metastasis location showed that the positive rates in 8a, 12, 13, 14 and 17 groups lymph nodes were respectively 5.4%(2/37), 18.9%(7/37), 21.6%(8/37), 8.1%(3/37) and 10.8%(4/37); Perineural invasion (PNI), lymphovascular invasion (LVI), pancreatic invasion and duodenal invasion were identified in 14, 9, 16 and 6 patients, respectively. TNM stage: stage 0, ⅠA, ⅠB, ⅡA and ⅡB were respectively detected in 1, 3, 5, 12 and 16 patients. (3) Follow-up situation: of 37 patients, 36 were followed up for 6-45 months, with a median time of 26 months. The median recurrence-free survival time, 1- and 3-year recurrence-free survival rates were respectively 28 months, 80.6% and 42.2%.
Conclusion:LPD is safe and effective for distal cholangiocarcinoma, and “en-block” resection not only helps to optimize the process of LPD for distal cholangiocarcinoma, but also has a significant effect on R₀ resection and lymph node dissection.