ANZ J. Surg. 2005; 75: 520–523 ORIGINAL ARTICLE ORIGINAL ARTICLE REOPERATIVE PANCREATICODUODENECTOMY FOR PERIAMPULLARY CARCINOMA PARUL J. SHUKLA, SAJID S. QURESHI, SHAILESH V. SHRIKHANDE, PALEPU JAGANNATH AND LUIS J. DESOUZA Department of Gastrointestinal Surgery, Tata Memorial Hospital, Parel, Bombay, India Background: Potentially resectable periampullary tumours may not be treated appropriately due to lack of local expertise in both assessment of resectability and resection in referring centres. Tata Memorial Hospital is a major referral centre for oncology and these patients are finally referred to this institution. In carefully selected patients, resection can be accomplished. The purpose of the present paper was to determine the perioperative morbidity and mortality for patients undergoing reoperative pancreaticoduodenec- tomy at a major comprehensive cancer centre. Methods: Between January 1991 and December 2001 15 patients, who had undergone previous non-resectional surgery for opera- ble periampullary carcinoma, underwent re-exploration. The perioperative morbidity and mortality were analysed and compared with that of the group of patients undergoing primary pancreaticoduodenectomy (143 patients) in the same period. Results: All the 15 patients undergoing re-exploration had a successful resection by pancreaticoduodenectomy. In the reoperative group eight patients (53%) underwent classic pancreaticoduodenectomy and seven patients (46%) had a pylorus-preserving pan- creaticoduodenectomy, as compared to 102 (71%) and 41 (29%) patients in the primary surgery group, respectively. Although the mean operative time and the estimated blood loss were higher in the reoperative group, the morbidity and mortality rates were similar in the two groups. The overall 30-day mortality rate was 6.6% and 6.9% in the reoperative and the primary surgery group, respectively. Major morbidity occurred in two of the 15 patients (13.3%), and one patient (6.6%) died following surgery in the reoperative group. Conclusion: Reoperative pancreaticoduodenectomy can be performed safely in carefully selected patients with resectable, local- ized periampullary tumours with similar morbidity and mortality to patients undergoing primary surgery. Key words: morbidity, mortality, pancreaticoduodenectomy, reoperation. Abbreviations: CBD, common bile duct; CPD, classic (Whipple’s) pancreaticoduodenectomy; CT, computed tomography; PD, pancreaticoduodenectomy; PPPD, pylorus-preserving pancreaticoduodenectomy. INTRODUCTION Surgical resection remains the only potential curative treatment strategy for patients with periampullary tumours. An inordinately high complication rate and a hospital mortality of 25% led some to suggest that pancreaticoduodenectomy (PD) should be aban- doned. 1,2 However, in recent years, with improvements in surgi- cal techniques and postoperative management the outcome has improved, with many centres reporting hospital mortality rates <5%. 3–6 Our own recent experience with PD in a prospective database has shown a mortality rate of <5% over the past 3 years (2001–2003: 2.7% mortality rates for 73 consecutive patients). Because of these favourable outcomes, a number of series on reoperation for periampullary tumours considered unresectable at prior exploration have been reported, with most of the series acknowledging the safety and similar outcomes in terms of resectability, morbidity, mortality and survival. 7–13 The aim of the current study was to present our experience with reoperation in 15 patients and to compare their perioperative outcomes with patients undergoing primary surgery in the same period at Tata Memorial Hospital, Bombay. METHODS Fifteen patients underwent re-exploratory surgery for periampul- lary tumours at Tata Memorial Hospital between January 1991 and December 2001. All these patients had undergone a laparot- omy for planned PD prior to referral to our institution. The median interval between the initial surgery and second exploratory surgery was 87 days (mean 99 days; range 13– 256 days). Pretreatment evaluation included physical examina- tion; routine laboratory investigation, chest radiography and con- trast-enhanced computed tomography (CT) in all patients. Upper gastrointestinal endoscopy and endoscopic ultrasound were done at the discretion of the attending surgeon. Patients were required to fulfil strict CT criteria for resectability, which were (i) the absence of extrapancreatic disease; (ii) no evidence of tumour encasement of the superior mesenteric artery or celiac axis as defined by the presence of a normal fat plane between the tumour and these arterial structures; and (iii) a patent superior mesenteric– portal venous confluence. Surgical management for periampullary tumours included classic (Whipple’s) pancreaticoduodenectomy (CPD), and pylorus- preserving pancreaticoduodenectomy (PPPD). The PPPD was routinely done whenever feasible, and CPD was performed when a previous gastrojejunostomy was done or when severe postoper- ative adhesions prevented a safe dissection of the first part of the duodenum. Pancreaticojejunostomy or pancreaticogastrostomy using the duct-to-mucosa technique accomplished pancreatic– enteral reconstructions. Biliary–enteric anastomoses were all end-to-side hepaticojejunostomies performed in single layer with P. J. Shukla MS, FRCS; S. S. Qureshi MS, DNB; S. V. Shrikhande MS; P. Jagannath MS, FACS; L. J. DeSouza MS, FRCS. Correspondence: Dr Parul Shukla, Department of Gastrointestinal Surgery, Tata Memorial Hospital. Ernest Borges Road, Parel, Bombay, India. Email: pjshukla@doctors.org.uk Accepted for publication 21 February 2005.