Abstract: Objective:To investigate the application value and clinical effect of the arteryfirst approach in radical pancreaticoduodenectomy.
Methods:The retrospective cohort study was adopted. The clinical data of 90 patients with ductal adenocarcinoma of the pancreatic head who were admitted to the First Affiliated Hospital of Xiamen University from February 2010 to August 2013 were collected. All the patients underwent radical pancreaticoduodenectomy, 40 undergoing arteryfirst approach were allocated into the arteryfirst approach group and 50 undergoing routine radical pancreaticoduodenectomy were allocated into the operation group. Observation indicators included (1) intraoperative situations: operation time, volume of blood loss, number of patients combined with portal vein (PV) resection and reconstruction, R0 resection and number of lymph node dissected, (2) postoperative situations: pathological examinations and complications, (3) results of followup: postoperative survival, tumor recurrence and metastasis. The patients were followed up by outpatient examination and telephone interview till August 2013. Measurement data with normal distribution were presented as ±s and analyzed using t test. Measurement data with skewed distribution were presented as M (range), and comparison between groups was analyzed by the Wilcoxon rank sum test. Count data were analyzed using the chisquare test or Fisher exact probability. Comparison of ranked data was done using the KruskalWallis rank sum test. The survival rate was calculated using KaplanMeier method and survival analysis was done using the Logrank test.
Results: (1) Intraoperative situations: all the patients underwent successful operation, without the occurrence of uncontrollable intraoperative bleeding. The operation time, volume of intraoperative blood loss and number of patients combined with intraoperative portal vein resection and reconstruction were (4.2±0.9)hours, 294 mL (range, 100-400 mL), 3 in the arteryfirst approach group and (4.1±0.6)hours, 489 mL (range, 100-1 100 mL), 3 in the operation group, respectively, with no statistically significant difference between the 2 groups (t=1.05, U= 1.43, χ²=0.00, P>0.05). The rate of R0 resection was 82.5% (33/40) in the arteryfirst approach group and 62.0% (31/50) in the operation group, showing a statistically significant difference between the 2 groups (χ²=4.55, P<0.05). The number of lymph node dissected was 12.2±1.5 in the arteryfirst approach group and 11.3±1.2 in the operation group, showing no statistically significant difference between the 2 groups (t=1.61, P>0.05). (2) Postoperative situations: the results of pathological examinations showed that all the 90 patients were confirmed as with ductal adenocarcinoma of the pancreatic head. The stage Ⅰ, Ⅱ, Ⅲ and Ⅳ of TNM stage were detected in 4, 12, 19, 5 patients in the arteryfirst approach group and 6, 17, 23, 4 in the operation group, respectively, showing no statistically significant difference between the 2 groups (χ²=5.84, P>0.05). Twenty patients (1 with biliary fistula, 4 with pancreatic fistula, 6 with gastric retention and 9 with diarrhea)in the arteryfirst approach group and 11 (3 with pancreatic fistula, 4 with gastric retention and 4 with diarrhea) in the operation group had postoperative complications, showing a statistically significant difference between the 2 groups (χ²=7.72, P<0.05). No perioperative death was occurred. (3) The results of followup: of 90 patients, 80 patients were followed up for a median time of 28 months (range, ²-40 months) and 10 patients lost to followup (4 in the arteryfirst approach group and 6 in the operation group). The 1 and 3 year survival rates were 97.2% and 52.8% in the arteryfirst approach group and 72.4% and 18.2% in the operation group, respectively, showing a statistically significant difference between the 2 groups (χ²=5.10, P<0.05). Fiftythree patients were dead during the followup, including 17 ［9 with local tumor recurrence and 11 with liver transplantation (3 with local tumor recurrence combined with liver transplantation)］ in the arteryfirst approach group and 36 ［20 with local tumor recurrence and 26 with liver transplantation (10 with local tumor recurrence combined with liver transplantation)］ in the operation group, with a statistically significant difference in the death between the 2 groups (χ²=8.00, P<0.05). Seven patients in the arteryfirst approach group and 10 patients in the operation group were complicated with intraabdominal metastasis, with no statistically significant difference (χ²=0.09, P>0.05).
Conclusion:The arteryfirst approach in radical pancreaticoduodenectomy can increase the R0 resection rate and reduce shortterm postoperative recurrence, meanwhile, improve the prognosis of patients.