Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome

Abstract

Objective: This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy).

Summary background data: Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection may improve long-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticized for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers.

Methods: Between April 1996 and December 1997, 114 patients with periampullary adenocarcinoma were enrolled in an ongoing, prospective, randomized trial at The Johns Hopkins Hospital. After intraoperative verification of completely resected periampullary adenocarcinoma, the patients were randomized to receive either a standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the specimen) or a radical pancreaticoduodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. The postoperative morbidity, mortality, and short-term outcomes were examined.

Results: Of the 114 patients randomized, 56 underwent a standard pancreaticoduodenectomy and 58 a radical pancreaticoduodenectomy. The two groups were statistically similar with regard to age and gender, but there was a higher percentage of white patients in the radical group. All the patients in the radical group underwent distal gastric resection, whereas 86% of the patients in the standard group underwent pylorus preservation. The mean operative time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two groups with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and two in the radical group. The complication rates were 34% for the standard group and 40% for the radical group. Patients undergoing radical resection had a higher incidence of early delayed gastric emptying but had similar rates of other complications, such as pancreatic fistula, wound infection, intraabdominal abscess, and need for reoperation. The mean total number of lymph nodes resected was higher in the radical group. Of the 58 patients in the radical group, only 10% had metastatic carcinoma in the resected retroperitoneal lymph nodes, and none of those patients had the retroperitoneal nodes as the only site of lymph node involvement. The 1-year actuarial survival rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group.

Conclusions: These data demonstrate that radical pancreaticoduodenectomy (with the addition of a distal gastrectomy and extended retroperitoneal lymphadenectomy to a standard pancreaticoduodenectomy) can be performed with similar morbidity and mortality to standard pancreaticoduodenectomy. However, the survival data are not sufficiently mature and the numbers of patients enrolled are not adequate to allow firm conclusions to be drawn regarding survival benefit.

Figure 1. Components of the radical procedure. (Left) The 30% to 40% distal gastrectomy specimen, which includes the pylorus and a 1- to 2-cm cuff of the duodenum. (Right) The retained stomach, the pancreatic body and tail, and an overview of the retroperitoneal dissection. Titanium clips have been placed to mark the extent of the retroperitoneal dissection. A celiac node is removed for histologic analysis.

Figure 2. The retroperitoneal dissection component of the radical procedure. The retroperitoneum is dissected from the hilum of the right kidney (K) to the left lateral border of the aorta (Ao) in the horizontal axis, exposing the left renal vein. In the vertical axis, the dissection extends from the level of the portal vein to below the level of the third portion of the duodenum (level of the inferior mesenteric artery [IMA] origin). Here, the gastric staple line and pancreatic remnant (P) are being retracted toward the upper right. The inferior vena cava (IVC) and aorta are fully exposed, and the right gonadal vein has been preserved. A curved vascular clamp gently occludes the inferior aspect of the bile duct. The retroperitoneal fat and lymph nodes are being resected en bloc (bottom right).

Figure 3. The actuarial survival curves for all patients who survived the immediate postoperative period, comparing the standard resection (n = 53) and the radical resection (n = 56) groups. The 1- and 2-year survival rates were 77% and 47% for the standard group and 83% and 56% for the radical group (p = 0.6; NS).

Figure 4. The actuarial survival curves for all patients with pancreatic adenocarcinoma who survived the immediate postoperative period, comparing the standard resection (n = 34) and the radical resection (n = 36) groups. The 1- and 2-year survival rates were 71% and 39% for the standard group and 80% and 48% for the radical group (p = 0.5; NS).

Figure 5. The actuarial survival curves for all patients with node-positive pancreatic adenocarcinoma (UICC stage 3) who survived the immediate postoperative period, comparing the standard resection (n = 25) and the radical resection (n = 24) groups. The 1-year survival rate was 72% for the standard group and 72% for the radical group (p = 0.9; NS).

Figure 6. The actuarial survival curves for all patients with node-negative pancreatic adenocarcinoma (UICC stage 1 and 2) who survived the immediate postoperative period, comparing the standard resection (n = 9) and the radical resection (n = 12) groups. The 1- and 2-year survival rates were 71% and 71% for the standard group and 92% and 71% for the radical group (p = 0.9; NS).