title: Subspecialization and pancreaticoduodenectomy: learning experience from 71 consecutive cases.
abstract: BACKGROUND
  Pancreaticoduodenectomy (PD) is a major procedure with significant mortality and morbidity. In this study, we reviewed our departmental results with PD as subspecialization for hepatopancreaticobiliary surgery developed, and evaluated the effects on surgical technique and practice.
  
  
  METHODS
  Between January 1995 and October 2000, 71 consecutive patients underwent PD for various diseases at our institution. Patients were analysed in two groups according to the 35-month time period in which they underwent surgery: Group A, January 1995 to November 1997 (n = 28), and Group B, December 1997 to October 2000 (n = 43).
  
  
  RESULTS
  The two groups were comparable for age, gender distribution, race and associated medical illnesses. Overall 30-day mortality was 5.6% (n = 4); three patients (10.7%) died in Group A and one (2.3%) in Group B. Compared to Group A, there was less surgery-related morbidity (25% vs 16.3%), intraoperative median blood loss (700 mL vs 500 mL), and median intensive-care stay (2 days vs 1 day) in Group B. No significant changes were noted in the overall complication rates (35.7% vs 39.5%), median operating time (4.7 vs 6.1 hours), median blood transfusion requirement (1.46 vs 1.29 units), and median hospital stay (17 vs 18 days). There was a significant shift away from pancreaticojejunostomy (PJ) reconstruction towards pancreaticogastrostomy (PG), especially in Group B. Although preoperative histological confirmation of carcinoma was important in the earlier group, there was less emphasis on this need for a diagnosis before resection in the later period.
  
  
  CONCLUSIONS
  Subspecialization in our department has improved the results of PD to an acceptable level, with a mortality of only 2.3%. However, this procedure still causes morbidity, with surgery-related morbidity of 16.3% even with subspecialization. Whether further reductions in morbidity can be achieved with more technical innovations remains to be seen. PG reconstruction was safer than PJ in our practice, with no anastomotic leaks.
authors.affiliation: Department of Surgery, Singapore General Hospital, Singapore.
authors.forename: John S
authors.initials: JS
authors.lastname: Yuen
authors.forename: London L
authors.initials: LL
authors.lastname: Ooi
authors.forename: Pierce K
authors.initials: PK
authors.lastname: Chow
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Chung
authors.forename: Lay W
authors.initials: LW
authors.lastname: Khin
authors.forename: Khee C
authors.initials: KC
authors.lastname: Soo
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods / Q000401:mortality* / Q000639:trends; D012189:Retrospective Studies