Objective To investigate the ten‑year evolution of pancreaticoduodenectomy (PD) for pancreatic head cancer and the improvement of prognosis in a single center.
Methods The retrospective cohort study was conducted. The clinicopathological data of 2 089 patients with pancreatic head cancer who were admitted to The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) from January 2015 to December 2024 were collected. There were 1 246 males and 843 females, aged 63.7(10.2) years. All patients underwent PD. Based on the time of admission, there were 931 cases from 2015 to 2019, and 1 158 cases from 2020 to 2024. Observation indicators: (1) conditions of patients; (2) surgical conditions; (3) postoperative conditions; (4) pathological examination results; (5) prognostic analysis. Comparison of measurement data with normal distribution between groups was conducted using the independent sample t test. Comparison of measurement data with skewed distribution between groups was conducted using the rank sum test. Comparison of count data between groups was conducted using the chi‑square test or Fisher exact probability. The Kaplan‑Meier method was used to plot survival curves and calculate survival rates, and the Log‑rank test was used for survival analysis.
Results (1) Conditions of patients: of the 2 089 patients, the total bilirubin level was 53.2(172.9) μmol/L, direct bilirubin was 51.7(123.3) μmol/L, preoperative albumin (Alb) was 38.6(5.8) g/L, alanine aminotransferase (ALT) was 64.9(141.5) U/L, aspartate aminotransferase was 82.5(199.7) U/L, and CA19‑9 level was 166.4(486.3) kU/L. A total of 26 patients received neoadjuvant therapy. There were significant differences in age, preoperative Alb, and ALT between patients admitted in different periods (t=2.97, Z=7.32, 3.04, P<0.05), and there was also a significant difference in neoadjuvant therapy (P<0.05). (2) Surgical conditions: of the 2 089 patients, open PD was performed in 1 933 cases, and laparoscopic or robotic‑assisted PD was performed in 156 cases. Standard PD was performed in 1 072 cases, and pylorus‑preserving PD was performed in 1 017 cases. Combined portal vein-superior mesenteric vein resection was performed in 498 cases, combined arterial divestment was performed in 284 patients, and combined arterial resection was performed in 15 cases. PD was performed in 34 cases with the discovery of tumor distant metastasis during surgery. In 66 cases, the resection range was expanded due to tumor invasion and concomitant resection of other organs was performed. The operation time of the 2 089 patients was 272(105) minutes, the volume of intraoperative blood loss was 200(200) mL, and there were 574 cases with intraoperative blood transfusion. There were significant differences in surgical procedure, portal vein-superior mesenteric vein resection, combined arterial divestment, concomitant resection of other organs, operation time, the volume of intraopera-tive blood loss, blood transfusion between patients admitted in different periods (χ²=7.66, 47.83, 56.59, 4.67, Z=3.85, 4.21, χ²=59.44, P<0.05), and there was also a significant difference in tumor distant metastasis (P<0.05). (3) Postoperative conditions: of the 2 089 patients, 842 cases had post-operative complications, including 349 cases of grade B or C pancreatic fistula, 170 cases of post-operative bleeding, 364 cases of delayed gastric emptying, 46 cases of biliary fistula, 37 cases of chylous fistula, 234 cases of abdominal infection, 66 cases of wound complications, 30 cases of reoperation, 24 cases of in‑hospital mortality, 18 cases of postoperative 30‑day mortality (30 cases of missing data), and 58 cases of postoperative 90‑day mortality (43 cases of missing data). The duration of postoperative hospital stay for the 2 089 patients was 14(10) days. There were signifi-cant differences in postoperative overall complications, delayed gastric emptying, abdominal infec-tion, wound complications, postoperative adjuvant chemotherapy and duration of postoperative hospital stay between patients admitted in different periods (χ²=5.14, 7.26, 5.82, 23.87, 9.02, Z=9.49, P<0.05). (4) Pathological examination results: of the 2 089 patients, results of postoperative pathological diagnosis showed ductal adenocarcinoma in 1 857 cases, intraductal papillary mucinous neoplasm with associated carcinoma in 89 cases, adenosquamous carcinoma in 68 cases, adenocarcinoma with other carcinomatous components in 19 cases, neuroendocrine carcinoma in 7 cases, squamous cell carcinoma in 3 cases, and other types in 46 cases. For tumor differentiation, 798 patients had well-to‑moderately differentiated tumors, 1 212 cases had poorly differentiated tumors, and 79 cases had missing data. For T stage, there were 283 cases of T1 stage, 1 165 cases of T2 stage, 293 cases of T3 stage, 333 cases of T4 stage, and 15 cases with missing data. For N stage, there were 685 cases of N0 stage, 941 cases of N1 stage, 456 cases of N2 stage, and 7 cases with missing data. For M stage, there were 2 048 cases of M0 stage and 41 cases of M1 stage. For tumor TNM stage, there were 496 cases of stage Ⅰ, 874 cases of stage Ⅱ, 674 cases of stage Ⅲ, 41 cases of stage Ⅳ, and 4 cases with missing data. For circumferential resection margin status, R0 resection was achieved in 902 cases, 1‑mm R1 resection was achieved in 881 cases, R1 resection was achieved in 305 cases, and data were missing for 1 case. The maximum tumor diameter of the 2 089 patients was 3.0(1.5) cm with data missing in 17 cases, the total number of lymph node dissected was 16(12), and the number of positive lymph node was 1(3) with data missing in 7 cases. There were significant differences in tumor differen-tiation degree, the total number of lymph node dissected, the number of positive lymph node, T stage, N stage, M satge, tumor TNM stage, and circumferential resection margin between patients admitted in different periods (χ²=16.83, Z=22.38, 2.83, χ²=30.39, 10.11, 32.09, 21.20, P<0.05), and there was also a significant difference in M stage (P<0.05). (5) Prognostic analysis: of the 2 089 patients, 1 999 cases were followed up for 43.8 months (95% confidence interval as 40.3-46.8 months). The median overall survival time was 22.7 months (95% confidence interval as 21.7-24.2 months), and 1‑, 3‑, 5‑year survival rates were 74.7% (95% confidence interval as 72.7%-76.6%), 34.5% (95% confidence interval as 32.2%-36.9%), 24.9% (95% confidence interval as 22.5%-27.3%), respectively. There were significant differences in median overall survival time between patients admitted in different periods, between patients with different tumor TNM stage, between patients with different tumor differentiation degree, between patients with different circumferential resection margin, between patients with or without postoperative adjuvant chemotherapy (χ²=49.88, 174.69, 90.71, 91.80, 52.83, P<0.05).
Conclusions Compared with patients admitted in 2015-2019, patients undergoing PD for pancreatic head cancer in 2020-2024 are characterized by elder age, increased utilization of laparoscopic or robotic surgery, higher ratios of combined venous resection and arterial divestment, longer operation time, increased overall postoperative complication rate. However, there is less intra-operative blood loss and no increase in surgery‑related mortality. Adjuvant chemotherapy after PD can significantly prolong the overall survival time of patients.
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