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Background
We have noted a continued increase in the number of patients referred to our institution
for presumed or biopsy-proven periampullary carcinoma following an “exploratory” laparotomy
during which tumor resection was not performed. Although previous work has demonstrated
the safety of reoperative pancreati-coduodenectomy PD), the need to avoid non-therapeutic
laparotomy in these patients is obvious. In the current study, we sought to determine
why PD was not performed at the initial operation.
Methods
Using the prospective pancreatic cancer database, we identified all patients who underwent
reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging
prior to reoperation was standardized and based on thin-section, contrast-enhanced
computed tomography (CT); helical CT was used in more recent cases. Pathologic data
were obtained, and initial outside operative reports were reviewed to determine why
a PD was not performed at the initial procedure.
Results
Twenty-nine patients underwent reoperative PD. Resection was not performed at the
initial laparotomy because of the surgeon's assessment of local unresectability (17
patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error
in intraoperative management (1). In the 17 patients deemed to have unresectable disease,
successful reoperative PD required vascular resection in 10. All 10 of these patients
had resection with negative microscopic margins of excision. Of the 9 patients who
did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple
intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma
confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered
major complications from intraoperative large-needle biopsy.
Conclusions
Detailed preoperative imaging and a clearly defined operative plan would have allowed
successful resection at the initial operation in 27 of 29 patients who underwent reoperative
PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly
against “exploratory” surgery in patients with presumed periampullary neoplasms.
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Article info
Footnotes
**Presented at the 48th Annual Meeting of the Southwestern Surgical Congress, Scottsdale, Arizona, April 28–May 1, 1996.
Identification
Copyright
© 1996 Excerpta Medica, Inc. All rights reserved. Published by Elsevier Inc.
