Surg Today (2008) 38:1152–1154DOI 10.1007/s00595-008-3746-2

Reprint requests to: H. UchidaReceived: November 15, 2007 / Accepted: February 3, 2008

Short Communication

Pylorus-Preserving Pancreaticoduodenectomy in Patients Undergoing Chronic Hemodialysis

HIROKI UCHIDA, KOHEI SHIBATA, SEIICHIRO KAI, KENTARO IWAKI, MASAYUKI OHTA, and SEIGO KITANO

Department of Surgery I, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita 879-5593, Japan

AbstractThis report describes three patients who underwent a pylorus-preserving pancreaticoduodenectomy (PpPD) and received maintenance hemodialysis due to chronic renal failure. The three cases were diagnosed to have bile duct cancer, intraductal papillary mucinous neo-plasm, and carcinoma of the ampulla of Vater, respec-tively. They underwent chronic hemodialysis for 7.7 years. They all underwent a PpPD with lymph node dissection. The mean operation time was 373 min and mean blood loss was 647 ml. During the postoperative courses, hemodialysis was restarted on postoperative day 1 in all three cases. In the three patients, only minor complications were experienced and these were treated conservatively. The mean postoperative hospital stay was 48 days. Two patients are still alive 135 and 21 months after the operation, respectively, but the other patient died of another disease 21 months after the PpPD. A PpPD may therefore be safe and feasible even in patients receiving chronic hemodialysis.

Key words Pancreaticoduodenectomy · Chronic renal failure · Hemodialysis

Pancreaticoduodenectomy (PD) is a standard treatment for various borderline and malignant diseases of the periampullary region. The associated mortality rate was once relatively high because of serious complications such as pancreatic leakage and gastrointestinal bleed-ing. However, the mortality rate has decreased with advances in surgical techniques and devices, and in medications, and interventional radiology.1–4

Patients with chronic renal failure requiring hemodi-alysis are usually immunocompromised and have various degrees of associated coagulopathy.5 Hemor-rhage, infection, and intra-abdominal abscess due to pancreatic leakage are the main causes of death after a PD. Therefore, a PD is considered to be indicated for patients with chronic renal failure. This report describes pylorus-preserving PDs (PpPD) performed in three patients with chronic renal failure requiring hemodialy-sis, which is based on a literature search of the PubMed database.

The three cases are summarized in Table 1. The diagnoses were bile duct cancer, mixed-type intraductal papillary mucinous neoplasm (adenoma), and carci-noma of the ampulla of Vater. The patient with bile duct cancer was classifi ed as stage II (T2N0) according to the General Rules for Surgical and Pathological Studies on Cancer of the Biliary Tract defi ned by the Japanese Society of Biliary Surgery.6 The patient with carcinoma of the ampulla of Vater was also diagnosed as stage II (T2N0). The patients had undergone chronic hemodialysis for an average of 7.7 years. All three underwent a PpPD with D1 or D2 lymph node dissec-tion according to the General Rules for Surgical and Pathological Studies on Cancer of the Biliary Tract and General Rules for the Study of Pancreatic Cancer.6,7 The mean operation time was 373 min and the mean blood loss was 647 ml. Hemodialysis was restarted on postoperative day 1 in all three cases. Only minor com-plications (cholangitis and minor pancreaticojejunos-tomy leakage) occurred, and these were managed conservatively. The mean postoperative hospital stay was 48 days. Two patients remain alive, one at 135 months and one at 21 months after the PpPD, but the third patient died of another disease 21 months after the PpPD.

Pancreaticoduodenectomy is a complicated and high-risk surgical procedure. It was performed successfully at the beginning of the 20th century, but it was seldom

H. Uchida et al.: PpPD in Patients Receiving Hemodialysis 1153

performed before 1935.8 The associated mortality rate was more than 25%, and therefore, PD remained a rare operation until the 1980s. After various institutions began reporting a decrease in their hospital mortality rates associated with this procedure, PD thus came into general use. Cameron et al. achieved a mortality rate of 1% in 1000 consecutive PDs and noted that the number of postoperative complication had dramatically de-creased.1 In recent years, radiologic intervention and postoperative management have also reduced the sever-ity of complications.9

Technical progress in the fi eld of blood purifi cation increases the lifespan of patients with chronic renal failure, thereby increasing the incidence of malignant tumors in these patients.10 In patients with chronic renal failure, the cell-mediated immune responses also dete-riorate according to the progression of renal insuffi -ciency. Because patients with chronic renal failure usually have specifi c particular conditions, such as elec-trolyte and coagulation abnormalities, immunocom-promise, poor wound healing, and fragile tissues,5 complications occur easily and are aggravated after surgery. Adam et al.11 showed an impaired renal func-tion to be an independent risk factor for postoperative morbidity. Therefore, a PD poses a great risk for patients with chronic renal failure. Although no reports of PDs in patients with chronic renal failure requiring hemodi-alysis were found, there are some reports of major abdominal surgery in patients with chronic renal failure. Cheng et al.12 reported no signifi cant differences in mor-bidity and mortality between patients with and without end-stage renal failure after a liver resection. Yamagata et al.13 presented data regarding hepatectomies in patients receiving maintenance hemodialysis. They sug-gested that a hepatic resection may be an acceptable

procedure for patients receiving hemodialysis, even though the morbidity rate in the hemodialyzed patients was signifi cantly higher than that for non-hemodialyzed patients.

In two of the patients described in the current study, the cancer was not at an advanced stage, and a com-bined resection of such vessels as the portal vein was not needed. There was no postoperative mortality, and only minor complications were observed. All three patients underwent hemodialysis on postoperative day 1, and the dialysis went smoothly, with no serious com-plications due to uremia. These results suggest that a PD may therefore be safely performed in patients receiving maintenance hemodialysis because of advances in perioperative management.

In conclusion, PpPDs were successfully performed in patients receiving chronic hemodialysis. The success in these cases suggests that a re-examination of the indica-tions for PD and PpPDs in patients undergoing mainte-nance hemodialysis is warranted.

References

1. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomy. Ann Surg 2006;244:10–5.

2. Böttger TC, Junginger T. Factors infl uencing morbidity and mor-tality after pancreaticoduodenectomy: critical analysis of 221 resections. World J Surg 1999;23:164–71.

3. Aranha GV, Hodul P, Creech S, Jacobs W. Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogas-trostomy. J Am Coll Surg 2003;197:223–31.

4. Suzuki Y, Fujino Y, Ajiki T, Ueda T, Sakai T, Tanioka Y, et al. No mortality among 100 consecutive pancreaticoduodenectomies in a middle-volume center. World J Surg 2005;29:1409–14.

5. Mailloux LU, Belluci AG, Wilkes BM, Napolitano B, Mossey RT, Lesser M, et al. Mortality in dialysis patients: analysis of the cause of death. Am J Kidney Dis 1991;18:326–35.

Table 1. Characteristics of the three chronic hemodialysis patients who underwent pancreaticoduodenectomies

Characteristic Patient 1 Patient 2 Patient 3 Mean

Age (years) 55 49 69 57Sex Male Male Male —Diagnosis CBD cancer Mixed type of IPMN Ampulla of Vater carcinoma —Renal disease Nephrosis Gouty kidney Nephrosclerosis —Period of hemodialysis (years) 10 9 4 8Stage II (adenoma) II —Operative procedure PpPD PpPD PpPD —Lymph node dissection D2 D1 D1 —Pancreatic anastomosis Jejunum Jejunum Jejunum —Operation time (min) 295 395 430 373Blood loss (ml) 1160 630 150 647Blood transfusion + + — —Complication Cholangitis Cholangitis Pancreatic leakage —Postoperative hospital stay (days) 59 42 42 48Postoperative survival (months) 135 21 21 59

CBD, common bile duct; IPMN, intraductal papillary-mucinous neoplasm; PpPD, pylorus-preserving pancreaticoduodenectomy

1154 H. Uchida et al.: PpPD in Patients Receiving Hemodialysis

6. Japanese Society of Biliary Surgery. General rules for surgical and pathological studies on cancer of biliary tract. 5th ed. Tokyo: Kanehara; 2003.

7. Japan Pancreas Society. General rules for the study of pancreatic cancer. 5th ed. Tokyo: Kanehara: 2002.

8. Whipple A, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg 1935;102:763–79.

9. Tanaka M. Gastroparesis after a pylorus-preserving pancreatico-duodenectomy. Surg Today 2005;35:345–50.

10. Maisonneuve P, Agodoa L, Gellert R, Stewart JH, Buccianti G, Lowenfels AB, et al. Cancer in patients on dialysis for end-stage renal disease: an international collaborative study. Lancet 1999;353:2111–5.

11. Adam U, Makowiec F, Riedinger H, Schareck WD, Benz S, Hopt UT. Risk factor for complication after pancreatic head resection. Am J Surg 2004;187:201–4.

12. Cheng SB, Wu CC, Shu KH, Ho WL, Chen JT, Yeh DC, et al. Liver resection for hepatocellular carcinoma in patients with end-stage renal failure. J Surg Oncol 2001;78:241–7.

13. Yamagata M, Kanematsu T, Matsumata T, Nishizaki T, Utsu-nomiya T, Sugimachi K, et al. Possibility of hepatic resection in patients on maintenance hemodialysis. Hepatogastroenterology 1993;40:249–52.