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1. INTRODUCTION
Periampullary cancers are a collection of malignant neoplasia of the periampullary region [6]. The 5-year survival rate of periampullary cancers is less than 15% for pancreatic cancer and quite low in ampullary cancer (39%), distal common bile duct’s cancers (27%), and duodenum cancer (59%) [1].
Pancreaticoduodenectomy is still the most radical treatment for periampullary cancer nowadays [2]. The mortality rate after surgery has been reduced by less than 2%, but the complications remain high, accounting for 30-50% [5]. Consequently, there are more than 3% of patients had to undergo re-operation or even dead.
In a study conducted by JP Lerut [10] on 103 patients with pancreaticoduodenectomy in treatment periampullary cancers, the rate of postoperative complication is about 19.4%, of which the pancreatic fistula complication is the most importantly, accounting for 14.5%. Factors related to postoperative complications were age (> 65 years), preoperative total bilirubin> 6 mg / dl, pancreatic parenchyma and the emergency degree of surgery. The complications of postoperative haemorrhage were also analyzed in the study by Sanjay P. et al. [15], suggesting that the related factors were the status of biliary obstruction, pancreatic parenchyma and pancreatic fistula.
In Viet Nam, post operation complications have never been monitored in patients underwent pancreaticoduodenectomy. Most of Vietnamese studies were only focus on the result of pancreatoduodenectomy [9], [13]. From that, we performed this study in order to discover some factors related to complications after pancreatoduodenectomy, especially short – term complications are necessary, to determine the ratio of short-term complications following pancreaticoduodenectomy and identification of the risk factors related to those complications.
2. MATERIALS AND METHOD
This is a retrospective cross-sectional study. Data has been retrospectively collected from medical records of all patients with periampullary cancer, who performed pancreaticoduodenectomy at Cho Ray Hospital from January 2012 to October 2016. Data analysis has been performed using SPSS 22.0. Qualitative variable is expressed in terms of numbers, frequency and analysed by Chi squared test. For descriptive analysis, continuous variables are expressed as mean and standard deviation (SD) and compared between groups using Student’s independent samples t test. The impact of complication risk-factors has been evaluated by Odds-ratio derived from a multivariate logistic regression analysis. The difference statistically significant when p < 0.05.
3. RESULTS AND DISCUSSION
There were 230 cases that suitable with the selected criteria in the sample. The survey included 109 males and 121 females, average age was 54 ± 11.5 years. Indication of pancreaticoduodenectomy included ampullary carcinoma in 113 cases (49.1%), pancreatic carcinoma in 82 cases (35.7%), distal CBD carcinoma in 31 cases (13.5%), and duodenum carcinoma in four cases (1.74%). Average postoperative hospitalization was 19.7 ± 11.2 days.
The overall complication rate was 25.65% and the mortality rate was 2.17%. As presented in Table 1, the most frequent complications include pancreatic fistula (10.43%) and followed by wound infection (4.38%).
As showed in Table 2, the aging over 65 years old was significantly associated with pancreatic fistula (p = 0.024). Monovarietal analysis showed that preoperative prealbumin that less than 20 g / dL had a statistically significant effect on pancreatic fistula rate (p = 0.034). The preoperative CA 19-9 greater than or equal to 100 U / mL had effect on pancreatic fistula (p = 0.018 by Chi squared test).
| Author | Year | Sample size | Pancreatic fistula rate | Risk factors | p |
|---|---|---|---|---|---|
| J.P.Lerut [10] | 1968-1981 | 103 | 14.50% | Age≥65 Preoperative Bilirubin≥6 mg/dl |
<0.01< 0.02 |
| Ying-Mo-Yang [17] | 2000-2003 | 66 | 10% | Diameter of Wirsung duct Pancreatic parenchyma | 0.007 0.017 |
| Schmidt C. [16] | 1980-2002 | 980-2002 | 9% | Preoperative biliary dranage Internal pancreato-jejono-anastomosis dranage | 0.07 0.001 |
| Nguyen Cao Cuong [12] | 2000-2007 | 73 | 8.2% | Diameter of Wirsung duct Pancreatic parenchyma | |
| Our study | 2011-2016 | 230 | 10.43% | Diameter of Wirsung duct Pancreatic parenchyma | 0.015 0.004 |
Two risk factors related to pancreatic fistula were pancreatic diameter of Wirsung’s duct and pancreatic tissue density.
The patients who have the soften pancreatic parenchyma would have the risk of surgical site infection by 4.588 times. but it was not statistically significant (p = 0.056). The risk of Hemoglobin less than 10 g / dl increased by 10 times in presence the risk of surgical site infection and was statistically significant (OR: 0.101. p = 0.014).
Pancreatic parenchyma increased the haemorrhage complication significantly (p = 0.04) (OR: 10.668. 95% confidence).
4. DISCUSSION
Short-term complication after pancreaticoduodenectomy was high 25.65%. including pancreatic fistula of 10.43%. followed by surgical site infection. abdominal abscess. haemorrhage and biliary leakage. Risk factors including age. preoperative tests. characteristics of surgery and postoperative pathology are considered with those short-term complications. Author Christopher L W. refer that age above 70, operation time and type of anastomosis are related to pancreatic fistula [4]. Diabetes is also one of the risk factor for complication [3].
Pancreatic fistula rate is 10.43%. This result is quite similar to J.P.Lerut [10]. We found a correlation between Wirsung duct’s diameter and pancreatic parenchyma with pancreatic fistula (p<0.05). This conclusion is also the same as DiMagno [7].
Treatment for pancreatic fistula mainly is preservation diet fasting parenteral nutrition and may be prescribed octreotide [14]. Five cases underwent reoperation to reconstruct pancreato-jejuno-anastomosis and drainage. There is a severe case resulted to death.
Infection of the incision: the rate is 4.38%. usually happened on the day of 9th after surgery and no case detected later than 23th postoperative day the patient was given antibiotics according to the antibiogramme cleansing the surgical site twice a day. The patient recovered within a week. Preoperative hemoglobin concentrations were associated with this complication (p = 0.014)
Haemorrhage after surgery accounted for 2.61%. According to Osamu Nakahara [11] in 2012 457 patients undergoing pancreaticoduodenectomy were noted that postoperative hemorrhage accounting for 2%. The pancreatic parenchyma was associated with this complication (p = 0.04). this result was also similar to Sanjay [15]. There might be mild haemorrhage was only detected through upper digestive endoscopy usually haemorrhage from the gastric-jejuno-anastomosis or there might be severe haemorrhage resulting to shock. Conservative treatment included hemostasis through endoscopy or intravascular intervention. Four cases had to undergo reoperation. Intra operation we detected haemorrhage from the left gastric artery or common hepatic artery. Two situations had severe haemorrhage after that.
Postoperative biliary leakage was rare. Only a few of studies had been reported this complication before. According to Courtney M. [5]. the postoperative biliary leakage rate was 2%. our study was 0.8%. It might be because patients in our study were well drained by placing a feeding tube through this anastomosis and draining outside the skin. Only two cases of postoperative biliary leaked during the follow-up period. None of the above risk factors were associated with biliary leakage complication.
Chyle leakage accounted for about 3.48%. It is slightly different from what discovered by author Kim (2013) in which Chyle leakage accounted for about 10.8% [8]. There are no risk factors associated with this complication.
5. CONCUSION
In particularly. there are two risk factors related to pancreatic fistula complication: Wirsung duct’s diameter less than 3mm and soften pancreatic parenchyma. Meanwhile. preoperative Hemoglobin concentrations were associated with surgical site infection. Pancreatic parenchyma is associated with haemorrhage complications. Understanding the risk factors associated with short-term complications after pancreaticoduodenectomy helps us in preparing preoperation and selecting the patient to perform surgery better.
