title: Lessons learned from 100 personal consecutive cases of pancreaticoduodenectomy at a university hospital in Thailand.
abstract: BACKGROUND
  Pancreaticoduodenectomy (PD) is a major operation with potential disastrous complications. Experience of the surgical team with high surgical volume is an important factor contributing to better outcome. The purpose of this study was to examine results of 100 consecutive cases of PD operated by the first author. Various aspects of this technically demanding operation related to our experience were discussed and reviewed.
  
  
  METHODS
  A retrospective study of 100 patients who had undergone PD during a period of 20.5 years was presented. The indications for PD were periampullary neoplasms or other symptomatic lesions at the pancreatic head. All patients had preoperative CT scan to evaluate extent of the disease and resectability. Preoperative biliary drainage was performed in selected cases. The operations were conducted in the same manner in most cases. Before 2000, no external drainage of the pancreatic remnant was used. Since 2000, external drainage of the pancreatic remnant was routinely used, except in one patient who had total pancreatectomy. Postoperative complications and mortality were studied.
  
  
  RESULTS
  Carcinoma of the ampulla of Vater and carcinoma of the head of the pancreas were the leading indications for PD (34% and 30%, respectively). No preoperative tissue diagnosis was made in patients who had carcinoma of the head of the pancreas. Two patients had emergency PD because of massive gastrointestinal bleeding. Sixty seven per cent underwent pylorus preserving PD (PPPD) and 33% underwent classical PD. Twenty eight patients had no external pancreatic drainage, 71 had external pancreatic drainage, and one had total pancreatectomy. The postoperative morbidity and mortality were 44% and 2%, respectively. The postoperative pancreatic fistula rate was higher in patients without external pancreatic stent but no statistical significance was detected (21.4% vs. 12.7%, NS). There was no mortality in patients aged > 70 years (n = 29) while two patients aged < 70 died (n = 71). The difference was not statistically significant.
  
  
  CONCLUSIONS
  PD could be safely performed with low pancreatic fistula and low mortality rate by experienced surgeons. Preoperative CT scan is extremely helpful in evaluation the extent of the disease and resectability. In patients with suspected carcinoma of the pancreatic head, PD should be performed without preoperative tissue diagnosis by experienced pancreatic surgeons. Elderly (aged > 70 years) is not a contraindication for PD. We strongly recommend the use of external pancreatic stent to prevent pancreatic fistula.
authors.affiliation: Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Suvit.s@chula.ac.th
authors.forename: Suvit
authors.initials: S
authors.lastname: Sriussadaporn
authors.forename: Sukanya
authors.initials: S
authors.lastname: Sriussadaporn
authors.forename: Rattaplee
authors.initials: R
authors.lastname: Pak-Art
authors.forename: Kritaya
authors.initials: K
authors.lastname: Kritayakirana
authors.forename: Supparerk
authors.initials: S
authors.lastname: Prichayudh
authors.forename: Pasurachate
authors.initials: P
authors.lastname: Samorn
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004322:Drainage; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D012189:Retrospective Studies; D013785:Thailand; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome