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Pancreaticoduodenectomy With or Without Distal Gastrectomy and Extended Retroperitoneal Lymphadenectomy for Periampullary Adenocarcinoma, Part 3: Update on 5-Year Survival
Taylor S. Riall, Johns Hopkins Medical Institutions, Baltimore, MD; John L. Cameron, Johns Hopkins, Baltimore, MD; Keith D. Lillemoe, Indiana University, Indianapolis, IN; Kurtis A. Campbell, Patricia K. Sauter, Johns Hopkins, Baltimore, MD; Joann Coleman, Johns Hopkins, Batlimore, MD; Ross A. Abrams, Rush University Medical Center, Chicago, IL; Ralph H. Hruban, Charles J. Yeo, Johns Hopkins, Baltimore, MD

Objective:
To evaluate 5-yr survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (PD).

Background:
A prospective randomized trial was performed (April 96-June 01) comparing survival after standard pylorus-preserving PD resection (standard) to survival after PD with distal gastrectomy and retroperitoneal lymphadenectomy (radical). An interim report (Ann Surg 1999;229:613) and report after closing the trial (Ann Surg 2002;236:355) showed no differences in survival between the standard and radical groups. Median live patient follow-up in this last report was only 31.5 mo. Furthermore, a quality of life analysis showed no differences between the two groups (J Gastrointest Surg 2003;7:1).

Methods:
299 margin negative patients were randomized to either the standard or radical group. 5 patients were excluded from final analysis for final pathology failing to reveal adenocarcinoma. The 5-yr survival of the two groups was evaluated. Results: Of the 294 patients analyzed (146 standard vs. 148 radical), the pathology and mortality rates were similar in the two groups. The median operative time was longer for radical resection (6.4 hr vs. 5.9 hr, p=0.002). The mean number of lymph nodes resected in the radical group was greater than the number resected in the standard group (28.5 vs. 17.0, p=0.001). The overall complication rate was 29% in the standard group and 43% in the radical group (p=0.01). The median live patient follow-up is now 64 mo. (5.33 yr). For all patients, those undergoing standard resection had 1- and 5-year survival rates of 79% and 33%, respectively, compared to 76% and 34% (p=0.98) for those patients in the radical group. There were no survival differences between the standard and radical groups when comparing node negative or node positive subgroups of patients. For pancreatic cancer patients, the 1- and 5-year survival rates in the standard group were 75% and 21%, respectively, compared to 78% and 29% in the radical group (p=0.75).

Conclusions:
The 5-yr survival data with a median follow-up of 64 mo. fail to demonstrate a survival difference between the entire cohort or any subgroup of patients undergoing standard versus radical resection. The increased morbidity rate, longer operative time and similar survival for radical PD lead us to conclude that pylorus-preserving PD without retroperitoneal lymphadenectomy should be the standard of care for patients with resectable periampullary adenocarcinoma.


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