| Background:(1)Pancreatojejunostomy has an important influence on the occurrence of pancreatic fistula after pancreaticoduodenectomy.The incidence of pancreatic fistula after Blumgart pancreatojejunostomy is relatively low,but the operation procedure is still relatively complicated.(2)The prognosis of pancreatic cancer is poor.Surgery,as the only possible method to cure cancer,has a very low proportion.Even among operable patients,more than 75% had recurrence within 2 years after surgery.The prognosis of patients with different recurrence sites was significantly different,but there was limited data on the recurrence patterns,and the results were inconsistent,the influencing factors of different recurrence patterns were still not clear.Objective:(1)Comparing the anastomosis between traditional pancreatojejunostomy anastomosis and Blumgart anastomosis,and the difference between classic and modified Blumgart in postoperative pancreatic fistula and other complications related to operations,so as to provide more clinical data support for the extensive using of classic Blumgart and modified Blumgart anastomosis.(2)Comparing the clinicopathological characteristics and survival differences between the major recurrence patterns,and to find the independent risk factors affecting different recurrence pattern after pancreatic cancer surgery,so as to help clinical work guide decision-making.Methods:(1)We retrospectively analyzed the data of 669 patients who underwent pancreaticoduodenectomy between January 2010 and December 2017 in our department.Aaccording to the pancreatic anastomosis method,patients were generally grouped into the traditional anastomosis group and Blumgart anastomosis group which can be further divided into classical Blumgart anastomosis and modified Blumgart anastomosis.Then we compared different groups in postoperative pancreatic fistula and other complications.(2)The patients with pancreatic ductal adenocarcinoma confirmed by pathologically among the 669 patients were followed up.They were divided into different groups according to the first postoperative recurrence site.Survival analysis was carried out for different recurrence patterns.Overall survival curve,recurrence free survival curve and survival after rucurrence curve were drawn to look for risk factors affecting the overall survival and different recurrence patterns after radical surgery of pancreatic cancer.Results:(1)The overall incidence of clinically relevant postoperative pancreatic fistula after Blumgart anastomosis was 9.4%(36/383),which was significantly lower than 16%(46/286)in the traditional anastomosis,p=0.006.There was no significant difference between the modified Blumgart anastomosis and the classic Blumgart anastomosis in clinically relevant pancreatic fistula,with 9.6%(21/219)and 9.1%(15/164),respectively,p=0.883.And both of them had excellent and stable performance in terms of the length of postoperative stay and postoperative mortality within 90 days,with p values of 0.47 and 0.651,respectively.The incidence of abdominal infection(26.9%/44.5%,p<0.001)and percutaneous drainage(9.6%/20.1%,p=0.005)after modified Blumgart anastomosis were lower than that of classic Blumgart anastomosis.(2)Among 163 patients with pancreatic cancer,121(74.2%)developed recurrence.The main patterns of recurrence were local-only 46(38%),liver-only 30(24.8%)and liver+local 28(23.1%).Other included systemic multiple metastasis,extensive abdominal metastasis,bone metastasis and lung metastasis in a total of 17(14%).The median and 95% confidence intervals(95% CI)of overall survival(OS)were 20 months(15.5-24.5).The 1-year,3-year and 5-year survival rates were 70.4%(95% CI: 63.4%-77.4%),34.9%(95% CI: 26.7%-43.1%),and 21.9%(95% CI: 12.9%-30.9%),respectively.Median OS of patients with local-only recurrence was 26 months(95% CI:17.7-34.3),significantly higher than 14 months(95% CI: 10-18)and 11 months(95% CI: 8.9-13.1)for liver-only and liver+local recurrence,with both p<0.001.The median survival after recurrence(SAR)of local-only recurrence were 12 months(95% CI: 6.2-17.8),significantly higher than 5 months(95% CI: 3.7-6.3)and 3 months(95% CI: 2.7-3.3)of liver-only and liver+local recurrence,with both p<0.001.Multivariate analysis showed that the duration of surgery,postoperative abdominal infection and adjuvant chemotherapy were independent factors affecting local-only recurrence.The degree of tumor differentiation and adjuvant chemotherapy were independent factors of liver±local recurrence.Conclusion: Compared with the traditional anastomosis,the method of Blumgart anastomosis can reduce the incidence of clinically relevant postoperative pancreatic fistula and other serious complications.Our modified-Blumgart anastomosis method maintained a low rate of morbidity and mortality but with simplified procedures that can be easily put into practice.This technique can be used widely with excellent safety for pancreatojejunostomy as a part of pancreaticoduodenectomy.Among the recurrence patterns after radical resection of PDAC,the main ways are local-only,liver-only and liver+local recurrence.Local-only recurrence has a slow tumor progression and good prognosis,while once combined with liver metastasis,rapid progression is often seen in this part of patients.Patients with short operative time,no postoperative abdominal infection,adjuvant chemotherapy were more likely to have local-only recurrence,while those with low degree of tumor differentiation,and without adjuvant chemotherapy were more likely to have liver-only or liver+local recurrence. |
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