Abstract: Objective:To investigate the clinical efficacy of pancreaticoduodenectomy using artery first approach and prior portal vein (PV)superior mesenteric vein (SMV) shunting for complicated pancreatic head tumors.
Methods:The retrospective cohort study was conducted. The clinicopathological data of 91 patients with pancreatic head cancer who were admitted to the Changhai Hospital of Navy Medical University from February 2011 to December 2016 were collected. Among 91 patients undergoing pancreaticoduodenectomy combined with vascular resection and reconstruction, 27 using artery first approach and PV-SMV shunting and reconstruction were allocated into the PD-PVR group, 23 using conventional approach were allocated into the PD-CVR group, and 41 receiving pancreaticoduodenectomy with vascular resection were allocated into the PD-SVR group. Observation indicators: (1) comparison of intra and postoperative situations among groups; (2) comparison of postoperative pathological results among groups; (3) comparison of postoperative survival among groups. Followup using outpatient examination and telephone interview was performed to detect postoperative survival up to December 2017. Comparisons among groups of count data were done by the chisquare test or Fisher exact probability. Measurement data with normal distribution were represented as ±s, comparisons among groups were analyzed using the AN-OVA, and pairwise comparison was done using the LSD method. Measurement data with skewed distribution were described as M(Q), comparison among groups was analyzed using the Kurskal-Wallis rank sum test, and pairwise comparison was done using the paired comparison with adjusted P value. Ordinal data were compared using the nonparametric test. The survival rate and curve were respectively calculated and drawn by the KaplanMeier method, and Logrank test was used for survival analysis.
Results:(1) Comparison of intra and postoperative situations among groups: operation time, time of hepatic inflow occlusion, volume of intraoperative blood loss, cases with intraoperative blood transfusion, length of PV or SMV removal , cases with vascular grafts, grading 1, 2, 3, 4 and 5 of ClavienDindo classification of postoperative complications and duration of hospital stay were respectively (274±36)minutes, (22±7)minutes, 1 661 mL (110 mL, 3 800 mL), 20, (5.6±1.4)cm, 6, 11, 1, 1, 1, 1, (20±7)days in the PD-PVR group and (281±41)minutes, (27±5)minutes, 1 888 mL (176 mL, 4 162 mL), 18, (5.4±1.5) cm, 3, 1, 8, 2, 0, 0, (21±7)days in the PD-CVR group and (201±36)minutes, (16±6)minutes, 1 052 mL (74 mL, 3 926 mL), 17, (3.2±2.0)cm, 5, 15, 2, 3, 1, 1, (13± 6)days in the PD-SVR group, with statistically significant differences among groups (F=37.060, 34.530, x²=13.771, 14.015, F=32.260, x²=39.309, F=19.880, P<0.05). Patients with postoperative complications were improved by symptomatic and supporting treatment. (2) Comparison of postoperative pathological results among groups: maximum tumour dimension was respectively (3.6±1.3)cm, (4.0±1.3)cm and (2.6±1.3)cm in the PD-PVR, PD-CVR and PD-SVR groups, with a statistically significant difference among groups (F=7.845, P<0.05). Cases with highdifferentiated, moderatedifferentiated and lowdifferentiated tumors of tumor differentiation, staging ⅡA and ⅡB of tumor staging, nerve invasion, positive lymph node, positive resection margins in neck of pancreas, bile duct and SMV were respectively 0, 13, 14, 17, 10, 17, 21, 0, 0, 0 in the PD-PVR group and 1, 12, 10, 10, 13, 15, 19, 1, 0, 0 in the PD-CVR group and 1, 29, 11, 17, 24, 30, 29, 2, 1, 1 in the PD-SVR group, with no statistically significant difference among groups (x²=4.122, 3.306, 0.902, 1.214, P>0.05). (3) Comparisons of postoperative survival among groups: of 91 patients, 52 were followed up for 3.069.3 months, with a median time of 18.0 months and followup rate of 57.1%(52/91), including 16 in the PD-PVR group and 14 in the PD-CVR group and 22 in the PD-SVR group. The median survival time, 1, 2 and 3year overall survival rates in 52 patients were respectively 16.6 months, 63.5%, 35.7% and 26.8%. The survival time in the PD-PVR, PD-CVR and PD-SVR groups were respectively 12.3 months (3.9-69.3 months), 15.0 months (3.0-63.3 months) and 20.0 months (6.0-65.2 months), with a statistically significant difference in survival among groups (x²=6.201, P<0.05), and between PD-PVR and PD-SVR groups (x²=4.412, P<0.05). There was no statistically significant difference in survival between PD-PVR and PD-CVR groups (x²=0.001, P>0.05).
Conclusion:Pancreaticoduodenectomy using artery first approach and PVSMV shunting and reconstruction for complicated pancreatic head tumors can reduce the time of hepatic inflow occlusion, it also contributes to the risk control of surgery for complicated pancreatic tumors, increases surgical safety and improves patients′ prognosis.