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Graded Morbidity Profiles for Duodenum Preserving Pancreatic Head Resection Are Equivalent To Those For Pancreaticoduodenectomy In Head-Dominant Chronic Pancreatitis
Olga Kantor*1, Jeffrey B. Matthews1, Mark S. Talamonti2, Waseem Lutfi2, Marshall Baker2
1Surgery, University of Chicago, Chicago, IL; 2Surgery, NorthShore University HealthSystem, Evanston, IL
Background: European randomized trials have compared duodenum preserving pancreatic head resection (DPPHR) to pancreaticoduodenectomy (PD) for management of head-dominant chronic pancreatitis (HDCP). These consistently demonstrate the improvements in pancreatitic pain and quality of life in DPPHR to be comparable to those following PD. Few studies from American centers have compared perioperative outcomes and no studies have graded the severity of postoperative complications following these procedures.
Methods: Medical records for patients undergoing either DPPHR or PD for HDCP between 2006 and 2014 were reviewed to capture all complications, postoperative interventions and 90-day readmission events. Clavien-Dindo grade IIIb, IV and V complications were classified as severe adverse postoperative outcomes (SAPO). Grade I, II, and IIIa complications requiring either prolonged length of stay (LOS) including readmissions (>3 standard deviations beyond the mean for patients without complications) or >1 interventional procedure were also classified as SAPO. All others were considered minor adverse outcomes (MAPO).
Results: 27 patients underwent DPPHR (3 Beger, 8 Berne, and 16 Frey procedures) and 20 underwent PD (12 standard, 8 pylorus-preserving). Patients undergoing DPPHR were less likely to have had significant weight loss prior to surgery than those undergoing PD (15% vs 50%, p=0.01). There were no other significant differences between surgical cohorts with regard to preoperative patient demographics, comorbidities including pre-existing diabetes and pancreatic exocrine insufficiency, alcohol history, or previous pancreatic surgery. There were no significant differences in rates of transfusion (7% vs 15%, p=0.64), postoperative complication (70% vs 60%, p=0.54), 90-day readmission (22% vs 20%, p=0.55), total LOS including readmissions (10.8 ± 5.4 vs 12.1 ± 6.8, p=0.43) or 90-day mortality (4% vs 0%, p=0.58) between groups. Patients undergoing DPPHR were less likely to suffer a postoperative pneumonia than those undergoing PD (0% vs 25%, p=0.01). Postoperative pancreatic fistula was infrequent in both groups (0% for DPPHR vs 10% for PD, p=0.18). There was a trend towards fewer SAPO among patients undergoing DPPHR although this did not reach significance (33% vs 50%, p=0.11). Multivariate regression adjusting for demographics, comorbidities, presenting symptoms, intraoperative blood loss, and procedure performed found no significant independent predictors of SAPO.
Conclusions: Although there is a trend towards a lower severity complication profile among patients undergoing DPPHR, graded 90-day perioperative outcomes of DPPHR are equivalent to those of PD. DPPHR procedures are performed seldomly in the United States. At experienced centers, these procedures are safe and provide complication profiles similar to more traditional surgical approaches to HDCP.
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