Outcomes and risk score for distal pancreatectomy with celiac axis resection (DP-CAR score): An international multicenter analysis

Abstract

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is performed in selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 16% 90-day mortality, highlighting the importance of patient selection. We constructed a risk score to predict 90-day mortality and assessed oncological outcomes. Methods: Retrospective, multicenter study in patients undergoing DP-CAR at 20 European centers (model design; 2000-2016) and three very-high volume international centers in the USA and Japan (model validation; 2004-2017). We used the area-under-receiver-operator-curve (AUC) and calibration plots for validation of the 90-day mortality risk model. Secondary outcomes assessed included oncological outcomes such as resection margin status, (neo)adjuvant therapy use and survival. Results: Among 191 DP-CAR patients, 90-day mortality was 5.5% (95CI: 2.2-11%) in 5 high-volume (≥1 DP-CAR/year) and 18% (95CI: 9-30%) in 18 low-volume DP-CAR centers (P=0.020). A risk score with age, sex, BMI, ASA, multivisceral resection, open versus minimally invasive surgery, and low versus high-volume center performed well in both, the design and validation cohort (AUC 0.79 versus 0.74, P value = 0.642) and calibration was adequate after adjustment. In 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapy was used in 69% and 67% of patients, and median overall survival was 19 (95CI 15-25) months. Conclusions: In selected patients operated in high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. We proposed a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as dominant predictor.