The "aborted" Whipple: why, and what happens next?

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Presenter: Rebecca Meltzer BA | Emory University Background: For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best chance of cure. A subset of patients is taken to the operating room for planned PD that is subsequently aborted. We reviewed these cases to determine reasoning for aborted PD, subsequent operative management, and patient outcome. Methods: Data from all patients between 2006-2019 who underwent exploratory laparotomy for planned PD for suspected or pathologically confirmed PAC were identified. From the operative notes, we identified the subset who were scheduled for PD with an intraoperative decision to abort and the reason why. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival. Results: 819 patients with PAC were taken to the operating room for PD in the specified interval, and 6.7% (n=55) of cases were aborted. Median age at diagnosis was 68 years in this cohort (range 43-85 years). 78% (n=43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n=10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n=36) and local invasion (34.5%, n=19). Of patients with metastatic disease, 75% (n=27) had liver metastases. 89% of patients underwent at least one palliative bypass procedure, including gastrojejunostomy (85.5%, n=47) or biliary bypass (87.0%, n=47), and 81.8% (n=45) had both gastric and biliary bypass. Patients who had only CT scans prior to surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% MRI, chi-squared = 3.54, p=0.059). The rate of postoperative complications was low, with surgical site infection being the most common (9.1%, n=5). The median length of stay was 7 days. Of 44 patients with a final diagnosis of PDAC, 62.8% (n=27) were aborted for metastatic disease and 37.2% (n=17) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days, 212 days for patients with distant metastases, and 540 days for patients with local invasion. Conclusion: With current imaging as a preoperative guide, the majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion, with a 6.7% rate of aborted operations. Intraoperative discovery of liver metastases is the most common reason for aborting PD, and the majority of these patients undergo successful gastric and biliary bypass with low rates of postoperative complications and acceptable survival. MRI prior to PD for PAC may improve the yield of identifying hepatic metastases.