Abstract
Introduction: Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). However, recent literature reported an increased clinical burden in patients undergoing pancreaticoduodenectomy (PD) following NACT. Therefore, the aim of our study was to assess the impact of NACT on postoperative outcomes and recovery after PD.Methods: A retrospective propensity score-matched study was performed including all patients who underwent PD for PDAC in a single center between 2015 and 2018. Patients treated with NACT for resectable, borderline resectable or locally advanced PDAC were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients who underwent upfront resection. Propensity scores were calculated using 7 perioperative variables, including gender, age, BMI, ASA score, Charlson-Deyo comorbidity score, fistula risk score (FRS), vascular resection. Primary outcome was the number and severity of complications at 90-days after surgery measured by the comprehensive complication index (CCI). Data are reported as median (IQR) or number of patients (%).Results: Of 283 resected patients, 95 (34%) were treated with NACT. Before matching, NACT patients were younger, had less comorbidities (Charlson-Deyo score 0 vs. 1, p = 0.04), similar FRS [2 (0–3) for both groups], and more vascular resections performed [n = 28 (30%) vs. n = 26 (14%), p < 0.01]. After propensity-score matching, preoperative and intraoperative characteristics were comparable. Postoperatively, CCI was similar between groups [8.7 (0–29.6) for both groups, p = 0.59]. NACT patients had a non-statistically significant increase in superficial incisional surgical site infections [n = 12 (13%) vs. 6 (6%), p = 0.14], while no difference was found for overall infectious complications and organ-space SSI. The occurrence of clinically-relevant pancreatic fistula was similar between groups [10 (11%) vs. 13 (14%), p = 0.51]. No difference was found between groups for length of hospital stay [8 (7–15) vs. 8 (7–14) days, p = 0.62], and functional recovery outcomes.Conclusion: After propensity score adjustment for perioperative risk factors, NACT did not worsen postoperative outcomes and functional recovery following PD for PDAC compared to upfront resection.
Highlights
Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC)
The adoption of preoperative chemotherapy for non-metastatic pancreatic cancer has increased significantly in recent years with the advent of more effective drug combination chemotherapy regimens, but there is still limited evidence on the effect of such treatment of surgical outcomes after pancreatectomy. In this propensity-score matched retrospective study performed at a high-volume referral center for pancreatic surgery, we found that preoperative combination chemotherapy did not increase postoperative morbidity nor worsen functional recovery
Preoperative chemotherapy is routinely offered to patients with locally advanced or borderline resectable disease
Summary
Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). Several factors could potentially affect postoperative outcome: (i) an impairment of liver and bone marrow function; (ii) a worsening of nutritional status and sarcopenia, which is known to impact on surgical outcomes [7]; (iii) the detrimental effect of a biliary stent placement in jaundiced patients, causing an increased morbidity in patients potentially candidate to upfront surgery [8]. Despite these risks, most published studies do not indicate an increase of complications in patients treated with neoadjuvant therapy, when compared to those undergoing upfront surgery [9,10,11]. Postoperative complications affect postoperative recovery and hospitalization costs, and could lead to reduced overall survival, compromising the potential advantage offered by preoperative treatment [12]
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