Extended Lymphadenectomy and Vein Resection for Pancreatic Head Cancer

HYPOTHESIS: An aggressive strategy that includes extended lymphadenectomy and vein resection may improve the results of surgical treatment of pancreatic head cancer. DESIGN: Nonrandomized control trial. SETTING: Tertiary care referral center. PATIENTS: The study included 149 consecutive patients undergoing macroscopically curative resection for periampullary adenocarcinoma from January 1, 1988, to December 31, 1998. INTERVENTIONS: A standard resection was performed in 122 cases; an extended lymphadenectomy in 37. Twenty-four patients underwent venous resection. MAIN OUTCOME MEASURES: Data on surgical mortality, morbidity, and postoperative outcome, pathological findings, and long-term survival were analyzed. RESULTS: In-hospital and 60-day operative mortality was 5.4%. Morbidity was 37.5%. Mortality, morbidity, and postoperative stay were nonsignificantly modified by extended lymphadenectomy or venous resection. Extended resection permitted the identification of a significantly higher percentage of nodal metastases beyond the peripancreatic node groups. In patients undergoing vein resection, a significantly higher rate of positive retroperitoneal margin was found. In the 100 patients with ductal adenocarcinoma, the median overall survival and the 5-year actuarial survival rate were 15 months and 8.4%, respectively. A trend toward a better survival was observed in the first 2 years after operation in the extended resection group compared with the standard resection group. Nodal status was the most powerful predictor of overall survival by multivariate analysis. CONCLUSIONS: Extended lymphadenectomy and vein resection did not adversely affect postoperative mortality and morbidity. Patients who required a vein resection were less likely to receive a microscopically curative pancreatectomy. Extended resection permitted better pathological staging and was associated with an early advantage in survival, but long-term survival was possible only in patients with favorable prognostic factors.