Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series

Journal of the Egyptian National Cancer Institute (2012) 24, 47–54

Cairo University

Journal of the Egyptian National Cancer Institute www.nci.cu.adu.eg www.sciencedirect.com

ORIGINAL ARTICLE

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series Amr Mostafa Aziz a,*, Ahmed Abbas b, Hisham Gad a, Osama H. Al-Saif b, Kam Leung a, Abdul-Wahed N. Meshikhes c,* a b c

Section of Hepato-pancreatico-biliary Surgery, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabia Section of Surgical Oncology, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabia Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabia

Received 16 May 2011; accepted 26 December 2011 Available online 24 February 2012

KEYWORDS Pancreatic cancer; Pancreaticoduodenectomy (PD); Complications; Survival

Abstract Context: Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. Objective: To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. Patients: Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. Design: Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. Results: Thirty-two patients (16 male and 16 female) with a mean age of 59.5 ± 12.7 years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n = 11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD,

* Corresponding authors. Tel.: +966 568093862 (A.M. Aziz), tel.: +966 3 843 111x6930; fax: +966 3 8551019 (A.-W.N. Meshikhes). E-mail addresses: [email protected] (A.M. Aziz), [email protected] (A.-W.N. Meshikhes). 1110-0362 ª 2012 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of Cairo University. doi:10.1016/j.jnci.2011.12.007

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A.M. Aziz et al. intra-operative blood loss P1 L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1 year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1 year were 52% vs 80%, respectively. Conclusion: PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity. ª 2012 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved.

Introduction The incidence of pancreatic adenocarcinoma is increasing and because of its silent course, late clinical symptoms and rapid growth patterns, it has been named the ‘‘silent killer’’ [1,2]. Pancreaticoduodenectomy (PD) is the treatment of choice, but it is one of the most complex surgical procedures, and is associated with substantial operative morbidity and mortality rates. The first successful PD was performed by the German surgeon, Kausch, in 1912 [3], and the operation was popularized in 1935 by Whipple et al. [4], who reported three cases of pancreaticoduodenal resection. Until the 1980s, the operative mortality rate of PD was 20–25%, and at one time some surgeons even proposed that it should be completely abandoned as a treatment option for carcinoma of the head of the pancreas [5,6]. A comprehensive review of the literature that included 1859 patients who underwent pancreatic resection for pancreatic cancer between 1980 and 1986 showed a mortality rate of 16%, which was unacceptably high when compared with other types of elective surgery [7]. In the 1990s, several major centers in western countries reported dramatically reduced operative mortality rates as a result of improved surgical management and increased experience [8–16]. An association between high procedure volume and better patient outcomes has been identified for numerous surgical procedures [17–21]. Several studies have linked the improved operative outcomes after PD in the 1990s with the concentration of case volume in specialized centers [10–13,15,16]. While an operative or in- hospital mortality rate of less than 5% had been achieved in high-volume centers, mortality rates in low-volume hospitals remained in the range of 13–20% in the 1990s [10–13,15,16]. In centers with a case volume of more than 40 per year, a mortality rate of less than 2% has been reported [9,14]. The most common indication for PD is carcinoma of the head of the pancreas [9,13,14]. With the improved safety, PD is also considered an appropriate treatment for selected patients with chronic pancreatitis, which is the second most common indication for the operation in the western series [9,14]. The aim of this article is to evaluate the outcome of PD in our newly-established specialized unit in Eastern Saudi Arabia, and compare it with the reports of well-established centers. Methods From January 2006 to December 2009, 102 patients with periampullary tumors were evaluated in King Fahad Specialist Hospital, Dammam, Saudi Arabia; 32 (31.4%) patients oper-

ated on with PD were retrospectively evaluated. All were operated and managed by a team of surgeons specialized in hepatopancreatic-biliary (HPB) surgery. Data on preoperative, intraoperative and postoperative care were collected and maintained on a secure database. Preoperative parameters included demographics, clinical presentation, preoperative risk factors, laboratory testing, and preoperative imaging modalities such as ultrasound, multi-detector abdominal CT with three-dimensional reconstructions, endoscopic retrograde cholangiopancreaticography (ERCP) with or without endoscopic stent drainage, endoscopic ultrasound and magnetic resonance cholangiopancreaticography. Intraoperative details such as operative time, total blood loss, transfusion needs and the type of surgical reconstruction were recorded. Postoperative events, complications, mortality, pathological data were also collected. Postoperative pancreatic fistula was defined as drainage of >50 mL per 24 h of fluid, with amylase content >3 times serum amylase activity for >10 d after operation [22]. Perioperative mortality was defined as death in the hospital or within 30 d [23]. Delayed gastric emptying (DGE) was defined to be present when nasogastric intubation was maintained for P10 d, combined with at least one of the following: vomiting after removal of the nasogastric tube, reinsertion of nasogastric tube, or failure to restore oral feeding [24]. Statistical analysis All continuous variables were expressed as a mean and standard deviation (SD) and compared using the Student’s t test. Categorical variables were compared using the Chi squared test with Fisher’s exact test to evaluate the impact of clinical and operative parameters – such as age, sex, any co-morbid illness, preoperative biliary drainage, nature of disease (malignant vs benign), type of operation (conventional vs pyloruspreserving PD), operative blood loss, and any perioperative transfusion – on postoperative morbidity. Survival estimates were generated using the Kaplan–Meier method. The disease-free survival (DFS) is defined as the length of time after surgical treatment during which a patient survives with no signs of local recurrence or distant metastasis. The overall survival (OS) is defined as the time elapsed between the date of admission and the date of last follow up or death. DFS was calculated from the date of operation to the date of definite presence of recurrence or death and the OS was calculated from the date of diagnosis to the date of death or last follow up visit. Statistical analysis was performed using SPSS statistical software. A P value 60.05 was considered statistically significant.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series Results

Table 2

There were 16 men and 16 women with a mean age of 59.5 (range, 24–82 years; SD 12.7) years. Twelve patients (37.5%) were elderly, aged 60 years or older. Twenty-three (71.9%) patients had one or more chronic co-morbid illnesses, mostly diabetes mellitus (53%) and hypertension (44%) (Table 1). Twenty-six patients (81%) underwent ERCP as part of their preoperative work up, with the insertion of biliary stents in 21 (66%) patients. Ampullary biopsy or brushing was taken from all patients, but came positive for malignancy in 11 (34%) cases only. Type of surgery and pancreato-enetric reconstruction Twenty-one patients (68.8%) underwent the classic PD, 10 (31.2%) pylorus-preserving PD and one (3.1%) underwent total pancreatectomy. Pancreatico–gastrostomy (PG) was done in 2 patients (6.2%), end-to-side pancreatico–jejonostomy (PJ) in 11 patients (34.4%), end-to-side duct-to-mucosa PJ in 15 patients (46.9%), end-to-end PJ (dunking) in 2 patients (6.2%), and pancreatic duct occlusion in 2 patients (6.2%). Two patients underwent concomitant procedures; segmental transverse colonic resection (n = 1) and venous patch graft for portal vein due to tumor infiltration (n = 1). The mean blood loss was 902.8 mL (range 300–2000 mL), but 13 (40.6%) patients did not receive any blood transfusion. Nineteen (59.4%) patients received a mean blood transfusion of 2.4 (range 1–4) units. The mean operative time was 6.9 (range from 4 to 12) hours. Malignant pathology was confirmed in 25 specimens (76%); the pathological diagnoses of the 32 patients are depicted in Table 2.

Table 1 Demographic and clinical presentation and comorbidities for patients with PD. Variable

Patient No. (%)

Age (mean ± SD) Male/female ratio

56.3 ± 12.7 years 1:1

Symptoms Jaundice Abdominal pain Weight loss Nausea Vomiting Pruritus Bleeding/melaena

29 (90.6%) 15 (46.9%) 16 (50%) 14 (43.8%) 7 (21.9%) 8 (25%) 2 (6.2%)

Co-morbidity Diabetes mellitus Hypertension Smoking Ischemic heart disease Chronic obstructive airway disease Chronic renal failure Hyperlipidemia Neurofibromatosis Alcoholic Sheehan’s syndrome

17 (53.1%) 15 (46.9%) 6 (18.8%) 3 (9.3%) 2 (6.2%) 1 (3.1%) 1 (3.1%) 1 (3.1%) 1 (3.1%) 1 (3.1%)

CA 19.9 elevation

21 (66%)

49

Pathologic data for the 32 patients with PD.

Pathological diagnosis

Patient No. (%)

Malignant pathology Pancreatic cancer Ampullary carcinoma Duodenal cancer Retroperitoneal germ cell tumor

25 (78.1) 14 (43.8) 9 (28.1) 1 (3.1) 1 (3.1)

Benign pathology Microcystic cystadenoma of pancreas Intraductal papillary mucinous neoplasm Lymphoplasmacytic sclerosing pancreatitis Pancreatic tuberculosis Mucinous cystic neoplasm

7 (21.9) 2 (6.2) 2 (6.2) 1(3.1) 1 (3.1) 1 (3.1)

Postoperative morbidity Complications were encountered in 17 (53%) cases. Pancreatic leak occurred in 5 cases (15.6%) which settled conservatively except in one case of pancreato–gastrostomy who was operated upon for gastric bleeding from anastomotic ulcer and obliteration of pancreatic duct was done using fibrin glue. Biliary leakage in 2 cases (6.2%) that did not respond to conservative treatment was managed by reoperation and repair of the leak. Bleeding from gastrointestinal anastomosis due to ulceration occurred in 2 patients (6.2%); one settled conservatively and the other was complicated by perforation and hence explored with closure of the site of perforation. Delayed gastric emptying occurred in 7 patients (21.9%) (4 post-pylorus preservation and 3 after classical PD). Wound infection occurred in 11 patients (34.4%); 2 (6.2%) were complicated by wound dehiscence, which was treated by re-suturing. Lymphatic leak occurred in one patient (3.1%) and was treated by fat-free diet and short chain fatty acids. The remaining complications are shown in Table 3. Table 4 shows postoperative morbidity according to different risk factors. Female gender, presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss P1 L, and perioperative blood transfusion were not associated with significantly increased morbidity. Sixteen patients (50%) had positive lymph nodes. All patients with positive lymph nodes or positive surgical margin received either postoperative chemotherapay or combined chemoradiotherapy. Postoperative mortality There was one (3.1%) hospital death in a female patient who had multiple preoperative co-morbidities (chronic renal failure, hypertension and diabetes mellitus). The case was complicated postoperatively by pancreatic leak, intra-abdominal abscess and sepsis that ended by multi-organ failure and death on the 28th postoperative day. ICU and hospital length of stay The mean ICU stay was 5 ± 7 d (range 1–30) and the mean hospital stay was 23 ± 21.3 d (range 7–96). Survival The cumulative overall (OS) and disease free survival (DFS) at 1 year were 80% and 82.3%, respectively (Figs. 1 and 2).The

50

A.M. Aziz et al.

Table 3

Complications of the 32 patients who underwent PD.

Postoperative morbidity

Type of pancreatic drainage

Patient No. (%)

Treatment

Pancreatic leak Bile leak Pancreatic fistula GI bleeding Delayed gastric emptying

1 2 1 2 4

5 2 2 2 7

Conservative Reoperation and repair Conservative 1 Conservative, 1 reoperation Conservative

Others Gastric leak Wound infection

Wound dehiscence Lymphatic leak Pleural effusion

Chest infection Colonic leak Jejunostomy tube leak

PG, 4 PJ duct-to-mucosa PJ duct-to-mucosa PG, 1 PJ duct-to-mucosa PG PPPD 3 CPD

1 PG, 1 PJ duct-to-mucosa 3 PJ end-to-side 6 PJ duct-to-mucosa 2 PG, 1 PD occlusion 1 PJ duct-to-mucosa 1 PJ end-to-side 1 PJ end-to-side 1 PG 2 PJ end-to-side 1 PJ duct-to-mucosa 1 PJ duct-to-mucosa 1 PJ end-to-side PJ duct-to-mucosa PJ duct to mucosa

(15.6) (6.2) (6.2) (6.2) (21.9)

2 (6.2) 11 (34.4)

Reoperation Conservative

2 (6.2)

Reoperation

1 (3.1) 4 (12.5)

Conservative Conservative

2 (6.2)

Conservative

1 (3.1) 1 (3.1)

Reoperation Conservative

PG : pancreatico-gastrostomy, PJ: pancreatico–jejonostomy, PPPD: pylorus preserving pancreaticoduodenectomy, CPD: classical pancreaticoduodenectomy, PD: pancreatic duct.

Table 4

Morbidity according to preoperative and operative factors.

Factor

Total No. of patients

No. of patients with morbidity (%)

P value

Age

<60 years (n = 20) P60 years (n=12)

9 (45) 8 (66.7)

0.20

Sex

Male (n = 16) Female (n = 16)

6 (37.5) 11 (68.8)

0.07

Co-morbid illness

No (n = 9) Yes (n = 23)

6 (66.7) 11 (47.8)

0.28

Biliary drainage

No (n = 11) Yes (n = 21)

6 (54.5) 11 (52.4)

0.60

Nature of disease

Benign (n = 7) Malignant (n = 25)

4 (57.1) 13 (52)

0.57

Operation

Classical PD (n = 22) PPPD (n = 10)

8 (36.4) 9 (90)

0.006a

Operative blood loss

<1 L (n = 22) P1 L (n = 10)

10 (45.5) 7 (70)

0.18

Operative transfusion

No (n = 13) Yes (n = 19)

6 (46.2) 11 (57.9)

0.38

PPPD: pylorus-preserving pancreaticoduodenectomy, PD: Pancreaticoduodenectomy. a P value 6 0.05 was considered statistically significant.

median OS was 45% at 30 months. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1 year were 52% vs 80%, respectively (Fig. 3). Discussion Many western centers had studied the perioperative morbidity and mortality of PD during the past decade [8–11,14]. In the 1970s, the mortality rate after PD was approximately 20%, but in recent decades, morbidity and mortality rates have de-

creased due to improvements in perioperative management and preoperative patient selection [25]. Ho and Heslin in their study indicated that both increased procedure volume and increased experience are associated with lower mortality rates for patients undergoing PD [26]. Our results are consistent with the ‘‘practice makes perfect’’ hypothesis originally proposed by Luft et al. [27]. Although increased years of experience are associated with lower mortality rates, the volume of procedures performed is more critical in achieving better outcomes. Indeed, all pancreatic resections

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series

Figure 1

Figure 2

The overall survival for the 32 patients with PD.

The DFS survival for the 32 patients with PD.

are technically demanding and require expert surgical and anesthetic care that can be achieved only through high volume and frequent repetition [10]. Moreover, experience with the treatment of complications requires the skills of diagnostic and interventional radiologists, critical care specialists, infectious disease, nursing, and nutritional support services [10]; so complications can be dealt with successfully by a multidisciplinary team. King Fahad Specialist Hospital (KFSH-D) is a newly established tertiary oncology facility that serves the population of the Eastern Province of Saudi Arabia (approximately 2.5 million inhabitants). Prior to establishment of the HPB section in the Province, majority of patients with pancreatic lesions were referred to a tertiary facility in Riyadh. Unfortunately, data concerning the outcome of PD in Saudi Arabia is lacking, making comparison of our results with that of tertiary centers in the country or other gulf countries difficult. Furthermore, comparison of our initial experience, which is of a small volume, with that reported from larger volume western units is not justifiable. Hence, this retrospective study was conducted to use the data as a base-line and to evaluate

51

Figure 3 The overall survival for patients with pancreatic cancer vs those with ampullary cancer.

our initial outcome of this operation to establish whether there is room for further improvement and also to analyze the factors that may influence morbidity or mortality after this operation in our Saudi population. Despite decrease in reported surgical mortality after PD, the surgical morbidity remains as high as 46–59% [8,9,14,28– 32]. The operative morbidity rate in our series is 53.1% which – although high – lies within the range reported from largevolume centers in the West. This is higher than the reported morbidity rates of approximately 40% after PD, despite remarkably reduced mortality rates in recent years [8,9,14,32]. This can be mainly attributed to the high wound infection that occurred in 11 cases (34.4%). Reoperation for postoperative complications was deemed necessary in 6 patients (18.75%) only. In other studies, reoperation ranged from 3.5% to 17% [14,16,25]. In our series, the pancreatic leakage is 15.6% which is within the rate reported by major western centers (10–20%) after PD, which has not declined significantly in the past 30 years [32]. Despite intensive effort to prevent pancreatic anastomotic leakage through the modification of surgical techniques or the use of prophylactic octreotide, none of the measures have been proven to be effective in reducing the pancreatic leakage rate [33]. Pancreatic leakage is a potentially serious complication that can lead to intra-abdominal sepsis and hemorrhage, and it has been associated with a mortality rate of 20–40% [34]. The high morbidity rate, but low mortality rate, in this study indicates that successful management of postoperative complications, such as pancreatic leak, plays an important role in achieving low mortality. The concerted efforts of the surgeons, intensive care staff, interventional radiologists, and clinical microbiologists in the management of postoperative complications are critical to the favorable outcome. Further improvement in the operative results of PD relies on measures to reduce postoperative morbidity. Analysis of risk factors of morbidity revealed that complications were close to significant in female patients (P = 0.07), but not significant for the presence of co-morbid illness, preoperative drainage, nature of tumors, type of operation, excessive blood loss and blood transfusion. Moreover, the morbidity rate was similar between elderly and

52 younger patients. Better preparation of patients with co-morbid illnesses and vigilant postoperative care may help reduce morbidity, but complications should be anticipated and managed in a timely fashion in such patients to avoid mortality. Patients with adequate preoperative biliary drainage and use of prophylactic antibiotics may help minimize postoperative complications. The role of preoperative biliary drainage is however controversial. The data in this study indicate that neither preoperative biliary drainage nor ‘no preoperative’ drainage was a risk factor for postoperative morbidity. Based on retrospective studies, some authors have reported increased postoperative morbidity and mortality after PD in patients with preoperative biliary drainage [35], but others have not observed increased morbidity associated with preoperative biliary drainage [36,37]. The role of biliary drainage for jaundiced patients before PD needs to be evaluated by a prospective randomized study. Reduction of operative blood loss by meticulous surgical techniques is probably the most practical measure that surgeons can employ to reduce postoperative morbidity. Other authors have demonstrated that operative blood loss is a major risk factor for complications after PD [38]. Excessive blood loss increases surgical stress and also entails the need for blood transfusion, both of which have been shown to exert an immunosuppressive effect and to increase postoperative morbidity, especially septic complications [39,40]. PD is still a long operation. In our study, the mean operative time was 6.9 h (range from 4 h to 12 h), which is comparable to other studies [29,34,47]. The mean hospital stay in our study was 23 ± 21.3 days (range 7–96 d). The hospital stay differs from study to study according to complications encountered in each study [25,29]. The hospital mortality rate in this series is 3.1%. In a study of the results of PD in 39 US hospitals, the hospital mortality after PD corresponded well to the work volume. Low-, medium-, and high-volume centers for PD were defined as 1–5 cases per year, 6–20 cases per year, and more than 20 cases per year, respectively. The corresponding hospital mortality rates were 19%, 12%, and 2.2%, respectively [11]. Other recent western studies using similar definitions have reported similar mortality rates in hospitals with different volumes of pancreatic resection [12,41]. Our institution would be classified as a medium-volume center according to such definition, but our hospital mortality rate was comparable to those mortality rates of high-volume western centers [11,12,16]. The largest single-institution experience of PD ever reported in the literature was from a center with 650 cases of PD between 1990 and 1996 (i.e. >100 cases per year), and the hospital mortality rate was 1.4 % [14]. The low hospital mortality rate observed in our study is likely to be related to the management of all patients by a specialized team of HPB surgeons, even though the case volume was not high. A study in the UK (1997) has demonstrated significantly lower postoperative mortality rate after resection of pancreatic and periampullary tumors in specialist pancreatic units compared with general surgical units (average mortality rate 4.9% vs 9.8%) [13]. A tertiary referral center is likely to offer better facilities and expertise in perioperative care, such as more sophisticated diagnostic imaging and radiological interventions, specialized anesthetic services, and a well equipped intensive care unit. Poon et al. stated that the experience of the surgical team is of equal, if not more important, when a complex operation

A.M. Aziz et al. is being performed only once a month or less frequently [42]. It is not only the operative technique, but also the perioperative management, that determine patients’ outcomes [42]. Between 1988 and 1993, 271 Whipple procedures were performed at Johns Hopkins, which enabled them to employ a dedicated intensive care unit with attending physicians and specialty support services [15]. This high volume of procedures led to the formulation of treatment protocols and critical pathways for the Whipple procedure, as well as standardization of diagnostic workups, technical operative details, and management of the postoperative course [43]. In a recent study (1998), hospital rather than individual surgeon’s case volume was identified as the most important determinant of hospital mortality rate after the resection of pancreatic cancer [41]. In the same study, the authors suggested that the combined ‘experience effect’ of the whole team of surgeons is more important than the number of operations performed by a particular surgeon, and the development of a systematic approach in perioperative management by a specialized team may be an important factor for better perioperative outcomes [41]. The association between higher volume and better outcomes for the Whipple procedure and all types of pancreatic resection has been used to recommend regionalization of these procedures either through minimum volume standards or referral of patients to ‘‘centers of excellence’’ [11,12,28,41,43–47]. The low operative mortality rate in our study, together with the data from western and eastern studies regarding the impact of hospital volume on perioperative outcomes seem to support the concentration of complex surgical procedures such as PD in our tertiary referral centers in the Eastern Province, Saudi Arabia. However, without a study that compares the operative outcomes of PD between various tertiary centers and general surgical units in the region, it is impossible to draw a conclusion. The influence of any confounding factors such as patient characteristics that may affect operative results in different institutions needs to be adjusted in such a study. Comparing survival following PD for patients with periampullary carcinomas in the last decade with several decades ago, survival is clearly improved from as high as 25% to as low as <5% [47]. In a study by Cameron et al. on 1000 PD for pancreatic cancer, those who had negative nodes and negative margins (patients presumably with small early pancreatic cancers) the 1-, 3-, and 5-year survival rates were 80%, 49%, and 41%, respectively [47]. The multiple reasons for the improved survival are not entirely clear. It is unlikely that surgery will play a significant role in the improvement of long-term survival following PD for periampullary adenocarcinomas. Further improvement will come from neoadjuvant and/or adjuvant therapy with radiotherapy and chemotherapy, as well as with immunotherapy [47]. The past 2 decades have seen a significant improvement in the way periampullary cancers are managed surgically. The next few decades will witness the introduction of improved neoadjuvant and adjuvant therapies which will certainly result in significant improvements in long-term survival [47].

Conclusion PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series high mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity. Conflict of Interest

[19]

[20]

The authors have no potential conflict of interest. [21]

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