title: Predictive factors of severe complications for ampullary, bile duct and duodenal cancers following pancreaticoduodenectomy: Multivariate analysis of a 10-year multicentre retrospective series.
abstract: BACKGROUND
  Postoperative outcomes following pancreaticoduodenectomy are well described for pancreatic cancers. Due to a lower incidence rate, complication rates and relative predictive factors are less detailed for ampullary, bile duct and duodenal cancers.
  
  
  METHODS
  Medical charts of patients operated on between 2001 and 2011 for an ampullary, bile duct or duodenal cancer were reviewed. Data were retrospectively studied with respect to demographics, surgical management, postoperative complications and histological findings. Specific complication rates were reported, and predictive factors for severe morbidity and mortality were determined by multivariate analysis.
  
  
  RESULTS
  135 patients were identified: 55 ampullary, 55 bile duct and 25 duodenal cancers. Twelve patients (8.9%) deceased postoperatively, and 36 others (26.7%) presented severe complications. Sixty-seven percent of the pancreas was soft, and pancreatic hardness was found to be the main protective factor against severe morbidity (HR = 0.36, 95% CI = 0.14-0.94, P = 0.037). Age and postpancreatectomy haemorrhage were independent predictors for death (HR = 14.63, 95% CI = 1.57-135.77, P = 0.018, and HR = 14.71, 95% CI = 2.86-75.62, P = 0.001, respectively). Only the use of an external transanastomotic duct stent significantly reduced both the morbidity (HR = 0.37, 95% CI = 0.16-0.83, P = 0.016), and the mortality (HR = 0.12, 95% CI = 0.02-0.69, P = 0.017).
  
  
  CONCLUSIONS
  Pancreaticoduodenectomy for ampullary, bile duct and duodenal cancers is a high-risk procedure. The systematic use of transanastomotic duct stents would significantly decrease the complication rate. Older patients should beneficiate from specific preoperative evaluation using an adapted index. Omental flap techniques to prevent a postpancreatectomy haemorrhage should be efficient. Effects of preoperative octreotid to harden the pancreas should be clarified.
authors.affiliation: Aix-Marseille University, APHM La Conception, Department of Surgery and Liver Transplantation, 147 Boulevard Baille, Marseille, France. Electronic address: stephane_bourgouin@hotmail.fr.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Bourgouin
authors.affiliation: Aix-Marseille University, Institut Paoli-Calmettes, Department of Oncologic Surgery, 232 Boulevard Sainte Marguerite, Marseille, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Ewald
authors.affiliation: Aix-Marseille University, APHM La Timone, Department of Public Health and Medical Information, 264 rue Saint Pierre, Marseille, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Mancini
authors.affiliation: Aix-Marseille University, APHM Hôpital Nord, Department of Visceral Surgery, Chemin des Bourrely, Marseille, France.
authors.forename: Vincent
authors.initials: V
authors.lastname: Moutardier
authors.affiliation: Aix-Marseille University, Institut Paoli-Calmettes, Department of Oncologic Surgery, 232 Boulevard Sainte Marguerite, Marseille, France.
authors.forename: Jean-Robert
authors.initials: JR
authors.lastname: Delpero
authors.affiliation: Aix-Marseille University, APHM La Conception, Department of Surgery and Liver Transplantation, 147 Boulevard Baille, Marseille, France.
authors.forename: Yves-Patrice
authors.initials: YP
authors.lastname: Le Treut
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D001650:Bile Duct Neoplasms / Q000150:complications / Q000601:surgery*; D003138:Common Bile Duct Neoplasms / Q000150:complications / Q000601:surgery; D004379:Duodenal Neoplasms / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011379:Prognosis; D019919:Prosthesis Implantation; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents
keywords: Ampulla of vater/pathology; Bile duct neoplasms; Duodenal neoplasms; Pancreaticoduodenectomy; Surgical outcomes