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Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A

retrospective case series

Article  in  Journal of the Egyptian National Cancer Institute · March 2012

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ORIGINAL ARTICLE

Pancreaticoduodenectomy in a tertiary referral center

in Saudi Arabia: A retrospective case series

Amr Mostafa Aziz a,*, Ahmed Abbas b, Hisham Gad a, Osama H. Al-Saif b,

Kam Leung a, Abdul-Wahed N. Meshikhes c,*

a Section of Hepato-pancreatico-biliary Surgery, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabiab Section of Surgical Oncology, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabiac Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabia

Received 16 May 2011; accepted 26 December 2011Available online 24 February 2012

KEYWORDS

Pancreatic cancer;

Pancreaticoduodenectomy

(PD);

Complications;

Survival

Abstract Context: Perioperative outcome of pancreaticoduodenectomy is related to work load

volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-bil-

iary (HPB) unit.

Objective: To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a

newly established HPB unit.

Patients: Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and

malignant indications.

Design: Retrospective collection of data on preoperative, intraoperative and postoperative care of

all patients undergoing PD.

Results: Thirty-two patients (16 male and 16 female) with a mean age of 59.5 ± 12.7 years were

analyzed. The overall morbidity rate was high at 53%. The most common complication was wound

infection (n= 11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases,

respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not

associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD,

* Corresponding authors. Tel.: +966 568093862 (A.M. Aziz), tel.:

+966 3 843 111x6930; fax: +966 3 8551019 (A.-W.N. Meshikhes).

E-mail addresses: amraziz055@yahoo.com (A.M. Aziz), meshi-

khes@gmail.com (A.-W.N. Meshikhes).

1110-0362 ª 2012 National Cancer Institute, Cairo University.

Production and hosting by Elsevier B.V. All rights reserved.

Peer review under responsibility of Cairo University.

doi:10.1016/j.jnci.2011.12.007

Production and hosting by Elsevier

Journal of the Egyptian National Cancer Institute (2012) 24, 47–54

Cairo University

Journal of the Egyptian National Cancer Institute

www.nci.cu.adu.egwww.sciencedirect.com

intra-operative blood loss P1 L, and perioperative blood transfusion were not associated with sig-

nificantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall

(OS) and disease free survival (DFS) at 1 year were 80% and 82.3%, respectively. The cumulative

overall survival for pancreatic cancer vs ampullary tumor at 1 year were 52% vs 80%, respectively.

Conclusion: PD is associated with a low risk of operative death when performed by specialized

HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate

remains high, mostly due to wound infection. Further improvement by reducing postoperative

infection may help curtail the high postoperative morbidity.

ª 2012 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V.

All rights reserved.

Introduction

The incidence of pancreatic adenocarcinoma is increasing andbecause of its silent course, late clinical symptoms and rapidgrowth patterns, it has been named the ‘‘silent killer’’ [1,2].

Pancreaticoduodenectomy (PD) is the treatment of choice,but it is one of the most complex surgical procedures, and isassociated with substantial operative morbidity and mortality

rates. The first successful PD was performed by the Germansurgeon, Kausch, in 1912 [3], and the operation was popular-ized in 1935 by Whipple et al. [4], who reported three cases

of pancreaticoduodenal resection. Until the 1980s, the opera-tive mortality rate of PD was 20–25%, and at one time somesurgeons even proposed that it should be completely aban-

doned as a treatment option for carcinoma of the head ofthe pancreas [5,6].

A comprehensive review of the literature that included 1859patients who underwent pancreatic resection for pancreatic

cancer between 1980 and 1986 showed a mortality rate of16%, which was unacceptably high when compared with othertypes of elective surgery [7]. In the 1990s, several major centers

in western countries reported dramatically reduced operativemortality rates as a result of improved surgical managementand increased experience [8–16]. An association between high

procedure volume and better patient outcomes has been iden-tified for numerous surgical procedures [17–21]. Several studieshave linked the improved operative outcomes after PD in the1990s with the concentration of case volume in specialized cen-

ters [10–13,15,16]. While an operative or in- hospital mortalityrate of less than 5% had been achieved in high-volume centers,mortality rates in low-volume hospitals remained in the range

of 13–20% in the 1990s [10–13,15,16]. In centers with a casevolume of more than 40 per year, a mortality rate of less than2% has been reported [9,14].

The most common indication for PD is carcinoma of thehead of the pancreas [9,13,14]. With the improved safety, PDis also considered an appropriate treatment for selected patients

with chronic pancreatitis, which is the second most commonindication for the operation in the western series [9,14].

The aim of this article is to evaluate the outcome of PD inour newly-established specialized unit in Eastern Saudi Arabia,

and compare it with the reports of well-established centers.

Methods

From January 2006 to December 2009, 102 patients withperiampullary tumors were evaluated in King Fahad Specialist

Hospital, Dammam, Saudi Arabia; 32 (31.4%) patients oper-

ated on with PD were retrospectively evaluated. All were oper-ated and managed by a team of surgeons specialized in hepato-

pancreatic-biliary (HPB) surgery. Data on preoperative, intra-operative and postoperative care were collected and maintainedon a secure database. Preoperative parameters included demo-

graphics, clinical presentation, preoperative risk factors, labo-ratory testing, and preoperative imaging modalities such asultrasound, multi-detector abdominal CT with three-dimen-

sional reconstructions, endoscopic retrograde cholangiopan-creaticography (ERCP) with or without endoscopic stentdrainage, endoscopic ultrasound and magnetic resonance cho-langiopancreaticography. Intraoperative details such as opera-

tive time, total blood loss, transfusion needs and the type ofsurgical reconstruction were recorded. Postoperative events,complications, mortality, pathological data were also collected.

Postoperative pancreatic fistula was defined as drainage of>50 mL per 24 h of fluid, with amylase content >3 times ser-um amylase activity for >10 d after operation [22]. Periopera-

tive mortality was defined as death in the hospital or within 30 d[23]. Delayed gastric emptying (DGE) was defined to be presentwhen nasogastric intubation was maintained for P10 d, com-

bined with at least one of the following: vomiting after removalof the nasogastric tube, reinsertion of nasogastric tube, or fail-ure to restore oral feeding [24].

Statistical analysis

All continuous variables were expressed as a mean and stan-

dard deviation (SD) and compared using the Student’s t test.Categorical variables were compared using the Chi squaredtest with Fisher’s exact test to evaluate the impact of clinical

and operative parameters – such as age, sex, any co-morbid ill-ness, preoperative biliary drainage, nature of disease (malig-nant vs benign), type of operation (conventional vs pylorus-preserving PD), operative blood loss, and any perioperative

transfusion – on postoperative morbidity. Survival estimateswere generated using the Kaplan–Meier method. The dis-ease-free survival (DFS) is defined as the length of time after

surgical treatment during which a patient survives with nosigns of local recurrence or distant metastasis. The overall sur-vival (OS) is defined as the time elapsed between the date of

admission and the date of last follow up or death. DFS wascalculated from the date of operation to the date of definitepresence of recurrence or death and the OS was calculated

from the date of diagnosis to the date of death or last followup visit. Statistical analysis was performed using SPSS statisti-cal software. A P value 60.05 was considered statisticallysignificant.

48 A.M. Aziz et al.

Results

There were 16 men and 16 women with a mean age of 59.5

(range, 24–82 years; SD 12.7) years. Twelve patients (37.5%)were elderly, aged 60 years or older. Twenty-three (71.9%)patients had one or more chronic co-morbid illnesses, mostlydiabetes mellitus (53%) and hypertension (44%) (Table 1).

Twenty-six patients (81%) underwent ERCP as part of theirpreoperative work up, with the insertion of biliary stents in21 (66%) patients. Ampullary biopsy or brushing was taken

from all patients, but came positive for malignancy in 11(34%) cases only.

Type of surgery and pancreato-enetric reconstruction

Twenty-one patients (68.8%) underwent the classic PD, 10

(31.2%) pylorus-preserving PD and one (3.1%) underwent totalpancreatectomy. Pancreatico–gastrostomy (PG) was done in 2patients (6.2%), end-to-side pancreatico–jejonostomy (PJ) in11 patients (34.4%), end-to-side duct-to-mucosa PJ in 15 pa-

tients (46.9%), end-to-end PJ (dunking) in 2 patients (6.2%),and pancreatic duct occlusion in 2 patients (6.2%). Two pa-tients underwent concomitant procedures; segmental transverse

colonic resection (n= 1) and venous patch graft for portal veindue to tumor infiltration (n = 1). The mean blood loss was902.8 mL (range 300–2000 mL), but 13 (40.6%) patients did

not receive any blood transfusion. Nineteen (59.4%) patientsreceived a mean blood transfusion of 2.4 (range 1–4) units.The mean operative time was 6.9 (range from 4 to 12) hours.Malignant pathology was confirmed in 25 specimens (76%);

the pathological diagnoses of the 32 patients are depicted inTable 2.

Postoperative morbidity

Complications were encountered in 17 (53%) cases. Pancreaticleak occurred in 5 cases (15.6%) which settled conservatively

except in one case of pancreato–gastrostomy who was operatedupon for gastric bleeding from anastomotic ulcer and oblitera-tion of pancreatic duct was done using fibrin glue. Biliary leak-

age in 2 cases (6.2%) that did not respond to conservativetreatment was managed by reoperation and repair of the leak.Bleeding from gastrointestinal anastomosis due to ulceration

occurred in 2 patients (6.2%); one settled conservatively andthe other was complicated by perforation and hence exploredwith closure of the site of perforation. Delayed gastric emptyingoccurred in 7 patients (21.9%) (4 post-pylorus preservation and

3 after classical PD). Wound infection occurred in 11 patients(34.4%); 2 (6.2%) were complicated by wound dehiscence,which was treated by re-suturing. Lymphatic leak occurred in

one patient (3.1%) and was treated by fat-free diet and shortchain fatty acids. The remaining complications are shown inTable 3. Table 4 shows postoperative morbidity according to

different risk factors. Female gender, presence of co-morbid ill-ness, pylorus-preserving PD, intra-operative blood loss P1 L,and perioperative blood transfusion were not associated withsignificantly increased morbidity. Sixteen patients (50%) had

positive lymph nodes. All patients with positive lymph nodesor positive surgical margin received either postoperativechemotherapay or combined chemoradiotherapy.

Postoperative mortality

There was one (3.1%) hospital death in a female patient whohad multiple preoperative co-morbidities (chronic renal fail-ure, hypertension and diabetes mellitus). The case was compli-

cated postoperatively by pancreatic leak, intra-abdominalabscess and sepsis that ended by multi-organ failure and deathon the 28th postoperative day.

ICU and hospital length of stay

The mean ICU stay was 5 ± 7 d (range 1–30) and the mean

hospital stay was 23 ± 21.3 d (range 7–96).

Survival

The cumulative overall (OS) and disease free survival (DFS) at1 year were 80% and 82.3%, respectively (Figs. 1 and 2).The

Table 1 Demographic and clinical presentation and co-

morbidities for patients with PD.

Variable Patient No. (%)

Age (mean ± SD) 56.3 ± 12.7 years

Male/female ratio 1:1

Symptoms

Jaundice 29 (90.6%)

Abdominal pain 15 (46.9%)

Weight loss 16 (50%)

Nausea 14 (43.8%)

Vomiting 7 (21.9%)

Pruritus 8 (25%)

Bleeding/melaena 2 (6.2%)

Co-morbidity

Diabetes mellitus 17 (53.1%)

Hypertension 15 (46.9%)

Smoking 6 (18.8%)

Ischemic heart disease 3 (9.3%)

Chronic obstructive airway disease 2 (6.2%)

Chronic renal failure 1 (3.1%)

Hyperlipidemia 1 (3.1%)

Neurofibromatosis 1 (3.1%)

Alcoholic 1 (3.1%)

Sheehan’s syndrome 1 (3.1%)

CA 19.9 elevation 21 (66%)

Table 2 Pathologic data for the 32 patients with PD.

Pathological diagnosis Patient No. (%)

Malignant pathology 25 (78.1)

Pancreatic cancer 14 (43.8)

Ampullary carcinoma 9 (28.1)

Duodenal cancer 1 (3.1)

Retroperitoneal germ cell tumor 1 (3.1)

Benign pathology 7 (21.9)

Microcystic cystadenoma of pancreas 2 (6.2)

Intraductal papillary mucinous neoplasm 2 (6.2)

Lymphoplasmacytic sclerosing pancreatitis 1(3.1)

Pancreatic tuberculosis 1 (3.1)

Mucinous cystic neoplasm 1 (3.1)

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series 49

median OS was 45% at 30 months. The cumulative overall sur-vival for pancreatic cancer vs ampullary tumor at 1 year were52% vs 80%, respectively (Fig. 3).

Discussion

Many western centers had studied the perioperative morbidityand mortality of PD during the past decade [8–11,14]. In the1970s, the mortality rate after PD was approximately 20%,

but in recent decades, morbidity and mortality rates have de-

creased due to improvements in perioperative managementand preoperative patient selection [25]. Ho and Heslin in theirstudy indicated that both increased procedure volume and in-

creased experience are associated with lower mortality rates forpatients undergoing PD [26].

Our results are consistent with the ‘‘practice makes perfect’’

hypothesis originally proposed by Luft et al. [27]. Although in-creased years of experience are associated with lower mortalityrates, the volume of procedures performed is more critical in

achieving better outcomes. Indeed, all pancreatic resections

Table 3 Complications of the 32 patients who underwent PD.

Postoperative morbidity Type of pancreatic drainage Patient No. (%) Treatment

Pancreatic leak 1 PG, 4 PJ duct-to-mucosa 5 (15.6) Conservative

Bile leak 2 PJ duct-to-mucosa 2 (6.2) Reoperation and repair

Pancreatic fistula 1 PG, 1 PJ duct-to-mucosa 2 (6.2) Conservative

GI bleeding 2 PG 2 (6.2) 1 Conservative, 1 reoperation

Delayed gastric emptying 4 PPPD 3 CPD 7 (21.9) Conservative

Others

Gastric leak 1 PG, 1 PJ duct-to-mucosa 2 (6.2) Reoperation

Wound infection 3 PJ end-to-side 11 (34.4) Conservative

6 PJ duct-to-mucosa

2 PG, 1 PD occlusion

Wound dehiscence 1 PJ duct-to-mucosa 2 (6.2) Reoperation

1 PJ end-to-side

Lymphatic leak 1 PJ end-to-side 1 (3.1) Conservative

Pleural effusion 1 PG 4 (12.5) Conservative

2 PJ end-to-side

1 PJ duct-to-mucosa

Chest infection 1 PJ duct-to-mucosa 2 (6.2) Conservative

1 PJ end-to-side

Colonic leak PJ duct-to-mucosa 1 (3.1) Reoperation

Jejunostomy tube leak PJ duct to mucosa 1 (3.1) Conservative

PG : pancreatico-gastrostomy, PJ: pancreatico–jejonostomy, PPPD: pylorus preserving pancreaticoduodenectomy, CPD: classical pancreati-

coduodenectomy, PD: pancreatic duct.

Table 4 Morbidity according to preoperative and operative factors.

Factor Total No. of patients No. of patients with morbidity (%) P value

Age <60 years (n= 20) 9 (45) 0.20

P60 years (n=12) 8 (66.7)

Sex Male (n= 16) 6 (37.5) 0.07

Female (n = 16) 11 (68.8)

Co-morbid illness No (n= 9) 6 (66.7) 0.28

Yes (n= 23) 11 (47.8)

Biliary drainage No (n= 11) 6 (54.5) 0.60

Yes (n= 21) 11 (52.4)

Nature of disease Benign (n = 7) 4 (57.1) 0.57

Malignant (n= 25) 13 (52)

Operation Classical PD (n= 22) 8 (36.4) 0.006a

PPPD (n= 10) 9 (90)

Operative blood loss <1 L (n= 22) 10 (45.5) 0.18

P1 L (n= 10) 7 (70)

Operative transfusion No (n= 13) 6 (46.2) 0.38

Yes (n= 19) 11 (57.9)

PPPD: pylorus-preserving pancreaticoduodenectomy, PD: Pancreaticoduodenectomy.a P value 6 0.05 was considered statistically significant.

50 A.M. Aziz et al.

are technically demanding and require expert surgical andanesthetic care that can be achieved only through high volumeand frequent repetition [10]. Moreover, experience with the

treatment of complications requires the skills of diagnosticand interventional radiologists, critical care specialists, infec-tious disease, nursing, and nutritional support services [10];so complications can be dealt with successfully by a multidis-

ciplinary team. King Fahad Specialist Hospital (KFSH-D) isa newly established tertiary oncology facility that serves thepopulation of the Eastern Province of Saudi Arabia (approxi-

mately 2.5 million inhabitants). Prior to establishment of theHPB section in the Province, majority of patients with pancre-atic lesions were referred to a tertiary facility in Riyadh.

Unfortunately, data concerning the outcome of PD in SaudiArabia is lacking, making comparison of our results with thatof tertiary centers in the country or other gulf countries diffi-

cult. Furthermore, comparison of our initial experience, whichis of a small volume, with that reported from larger volumewestern units is not justifiable. Hence, this retrospective studywas conducted to use the data as a base-line and to evaluate

our initial outcome of this operation to establish whether thereis room for further improvement and also to analyze the fac-tors that may influence morbidity or mortality after this oper-ation in our Saudi population.

Despite decrease in reported surgical mortality after PD,the surgical morbidity remains as high as 46–59% [8,9,14,28–32]. The operative morbidity rate in our series is 53.1% which

– although high – lies within the range reported from large-volume centers in the West. This is higher than the reportedmorbidity rates of approximately 40% after PD, despite

remarkably reduced mortality rates in recent years[8,9,14,32]. This can be mainly attributed to the high woundinfection that occurred in 11 cases (34.4%). Reoperation for

postoperative complications was deemed necessary in 6 pa-tients (18.75%) only. In other studies, reoperation ranged from3.5% to 17% [14,16,25].

In our series, the pancreatic leakage is 15.6% which is with-

in the rate reported by major western centers (10–20%) afterPD, which has not declined significantly in the past 30 years[32]. Despite intensive effort to prevent pancreatic anastomotic

leakage through the modification of surgical techniques or theuse of prophylactic octreotide, none of the measures have beenproven to be effective in reducing the pancreatic leakage rate

[33]. Pancreatic leakage is a potentially serious complicationthat can lead to intra-abdominal sepsis and hemorrhage, andit has been associated with a mortality rate of 20–40% [34].

The high morbidity rate, but lowmortality rate, in this study

indicates that successful management of postoperative compli-cations, such as pancreatic leak, plays an important role inachieving low mortality. The concerted efforts of the surgeons,

intensive care staff, interventional radiologists, and clinicalmicrobiologists in the management of postoperative complica-tions are critical to the favorable outcome. Further improve-

ment in the operative results of PD relies on measures toreduce postoperative morbidity. Analysis of risk factors of mor-bidity revealed that complications were close to significant in fe-

male patients (P = 0.07), but not significant for the presence ofco-morbid illness, preoperative drainage, nature of tumors,type of operation, excessive blood loss and blood transfusion.Moreover, the morbidity rate was similar between elderly and

Figure 1 The overall survival for the 32 patients with PD.

Figure 2 The DFS survival for the 32 patients with PD.

Figure 3 The overall survival for patients with pancreatic cancer

vs those with ampullary cancer.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series 51

younger patients. Better preparation of patients with co-morbid

illnesses and vigilant postoperative care may help reduce mor-bidity, but complications should be anticipated and managedin a timely fashion in such patients to avoid mortality. Patientswith adequate preoperative biliary drainage and use of prophy-

lactic antibiotics may help minimize postoperative complica-tions. The role of preoperative biliary drainage is howevercontroversial. The data in this study indicate that neither preop-

erative biliary drainage nor ‘no preoperative’ drainage was arisk factor for postoperative morbidity. Based on retrospectivestudies, some authors have reported increased postoperative

morbidity and mortality after PD in patients with preoperativebiliary drainage [35], but others have not observed increasedmorbidity associated with preoperative biliary drainage

[36,37]. The role of biliary drainage for jaundiced patients be-fore PD needs to be evaluated by a prospective randomizedstudy. Reduction of operative blood loss by meticulous surgicaltechniques is probably themost practical measure that surgeons

can employ to reduce postoperative morbidity. Other authorshave demonstrated that operative blood loss is a major riskfactor for complications after PD [38]. Excessive blood loss

increases surgical stress and also entails the need for bloodtransfusion, both of which have been shown to exert an immu-nosuppressive effect and to increase postoperative morbidity,

especially septic complications [39,40].PD is still a long operation. In our study, the mean opera-

tive time was 6.9 h (range from 4 h to 12 h), which is compara-ble to other studies [29,34,47]. The mean hospital stay in our

study was 23 ± 21.3 days (range 7–96 d). The hospital stay dif-fers from study to study according to complications encoun-tered in each study [25,29].

The hospital mortality rate in this series is 3.1%. In a studyof the results of PD in 39 US hospitals, the hospital mortalityafter PD corresponded well to the work volume. Low-, med-

ium-, and high-volume centers for PD were defined as 1–5cases per year, 6–20 cases per year, and more than 20 casesper year, respectively. The corresponding hospital mortality

rates were 19%, 12%, and 2.2%, respectively [11]. Other recentwestern studies using similar definitions have reported similarmortality rates in hospitals with different volumes of pancre-atic resection [12,41]. Our institution would be classified as a

medium-volume center according to such definition, but ourhospital mortality rate was comparable to those mortalityrates of high-volume western centers [11,12,16]. The largest

single-institution experience of PD ever reported in the litera-ture was from a center with 650 cases of PD between 1990and 1996 (i.e. >100 cases per year), and the hospital mortality

rate was 1.4 % [14].The low hospital mortality rate observed in our study is

likely to be related to the management of all patients by a spe-

cialized team of HPB surgeons, even though the case volumewas not high. A study in the UK (1997) has demonstrated sig-nificantly lower postoperative mortality rate after resection ofpancreatic and periampullary tumors in specialist pancreatic

units compared with general surgical units (average mortalityrate 4.9% vs 9.8%) [13].

A tertiary referral center is likely to offer better facilities

and expertise in perioperative care, such as more sophisticateddiagnostic imaging and radiological interventions, specializedanesthetic services, and a well equipped intensive care unit.

Poon et al. stated that the experience of the surgical team isof equal, if not more important, when a complex operation

is being performed only once a month or less frequently [42].

It is not only the operative technique, but also the periopera-tive management, that determine patients’ outcomes [42].Between 1988 and 1993, 271 Whipple procedures were per-formed at Johns Hopkins, which enabled them to employ a

dedicated intensive care unit with attending physicians andspecialty support services [15]. This high volume of proceduresled to the formulation of treatment protocols and critical path-

ways for the Whipple procedure, as well as standardization ofdiagnostic workups, technical operative details, and manage-ment of the postoperative course [43]. In a recent study

(1998), hospital rather than individual surgeon’s case volumewas identified as the most important determinant of hospitalmortality rate after the resection of pancreatic cancer [41]. In

the same study, the authors suggested that the combined ‘expe-rience effect’ of the whole team of surgeons is more importantthan the number of operations performed by a particularsurgeon, and the development of a systematic approach in

perioperative management by a specialized team may be animportant factor for better perioperative outcomes [41].

The association between higher volume and better outcomes

for the Whipple procedure and all types of pancreatic resectionhas been used to recommend regionalization of these proce-dures either through minimum volume standards or referral

of patients to ‘‘centers of excellence’’ [11,12,28,41,43–47].The low operative mortality rate in our study, together with

the data from western and eastern studies regarding the impactof hospital volume on perioperative outcomes seem to support

the concentration of complex surgical procedures such as PDin our tertiary referral centers in the Eastern Province, SaudiArabia. However, without a study that compares the operative

outcomes of PD between various tertiary centers and generalsurgical units in the region, it is impossible to draw a conclu-sion. The influence of any confounding factors such as patient

characteristics that may affect operative results in differentinstitutions needs to be adjusted in such a study.

Comparing survival following PD for patients with periam-

pullary carcinomas in the last decade with several decades ago,survival is clearly improved from as high as 25% to as low as<5% [47]. In a study by Cameron et al. on 1000 PD for pan-creatic cancer, those who had negative nodes and negative

margins (patients presumably with small early pancreatic can-cers) the 1-, 3-, and 5-year survival rates were 80%, 49%, and41%, respectively [47]. The multiple reasons for the improved

survival are not entirely clear. It is unlikely that surgery willplay a significant role in the improvement of long-termsurvival following PD for periampullary adenocarcinomas.

Further improvement will come from neoadjuvant and/oradjuvant therapy with radiotherapy and chemotherapy, as wellas with immunotherapy [47]. The past 2 decades have seen a

significant improvement in the way periampullary cancersare managed surgically. The next few decades will witnessthe introduction of improved neoadjuvant and adjuvant ther-apies which will certainly result in significant improvements

in long-term survival [47].

Conclusion

PD is associated with a low risk of operative death when per-formed by specialized HPB surgeons even in a tertiary referral

hospital. However, the postoperative morbidity rate remains

52 A.M. Aziz et al.

high mostly due to wound infection. Further improvement by

reducing postoperative infection may help curtail the highpostoperative morbidity.

Conflict of Interest

The authors have no potential conflict of interest.

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