Application of the artery-first approach in the radical pancreaticoduodenectomy

Objective To investigate the application value and clinical effect of the artery-first approach in radical pancreaticoduodenectomy. Methods The retrospective cohort study was adopted. The clinical data of 90 patients with ductal adenocarcinoma of the pancreatic head who were admitted to the First Affiliated Hospital of Xiamen University from February 2010 to August 2013 were collected. All the patients underwent radical pancreaticoduodenectomy, 40 undergoing artery-first approach were allocated into the artery-first approach group and 50 undergoing routine radical pancreaticoduodenectomy were allocated into the operation group. Observation indicators included (1) intraoperative situations: operation time, volume of blood loss, number of patients combined with portal vein (PV) resection and reconstruction, R0 resection and number of lymph node dissected, (2) postoperative situations: pathological examinations and complications, (3) results of follow-up: postoperative survival, tumor recurrence and metastasis. The patients were followed up by outpatient examination and telephone interview till August 2013. Measurement data with normal distribution were presented as ±s and analyzed using t test. Measurement data with skewed distribution were presented as M (range), and comparison between groups was analyzed by the Wilcoxon rank sum test. Count data were analyzed using the chi-square test or Fisher exact probability. Comparison of ranked data was done using the Kruskal-Wallis rank sum test. The survival rate was calculated using Kaplan-Meier method and survival analysis was done using the Log-rank test. Results (1) Intraoperative situations: all the patients underwent successful operation, without the occurrence of uncontrollable intraoperative bleeding. The operation time, volume of intraoperative blood loss and number of patients combined with intraoperative portal vein resection and reconstruction were (4.2±0.9)hours, 294 mL (range, 100-400 mL), 3 in the artery-first approach group and (4.1±0.6)hours, 489 mL (range, 100-1 100 mL), 3 in the operation group, respectively, with no statistically significant difference between the 2 groups (t=1.05, U= 1.43, χ2=0.00, P>0.05). The rate of R0 resection was 82.5% (33/40) in the artery-first approach group and 62.0% (31/50) in the operation group, showing a statistically significant difference between the 2 groups (χ2=4.55, P 0.05). (2) Postoperative situations: the results of pathological examinations showed that all the 90 patients were confirmed as with ductal adenocarcinoma of the pancreatic head. The stage Ⅰ, Ⅱ, Ⅲ and Ⅳ of TNM stage were detected in 4, 12, 19, 5 patients in the artery-first approach group and 6, 17, 23, 4 in the operation group, respectively, showing no statistically significant difference between the 2 groups (χ2=5.84, P>0.05). Twenty patients (1 with biliary fistula, 4 with pancreatic fistula, 6 with gastric retention and 9 with diarrhea)in the artery-first approach group and 11 (3 with pancreatic fistula, 4 with gastric retention and 4 with diarrhea) in the operation group had postoperative complications, showing a statistically significant difference between the 2 groups (χ2=7.72, P 0.05). Conclusion The artery-first approach in radical pancreaticoduodenectomy can increase the R0 resection rate and reduce short-term postoperative recurrence, meanwhile, improve the prognosis of patients. Key words: Pancreatic neoplasms; Pancreaticoduodenectomy; Superior mesenteric artery