Distal Pancreatectomy For Ductal Adenocarcinoma Research Articles

Extended Distal Pancreatectomy for Cancer of the Body and Tail of the Pancreas: Analysis of Early and Late Results.

Cancer of the body-tail of the pancreas often involves adjacent structures. Thus, surgical treatment may be extended to other organs or vessels in order to achieve radical resection. The aim of this study is to evaluate the safety and efficacy of extended distal pancreatectomy for ductal adenocarcinoma of the body and tail of the pancreas. Between January 2000 and December 2016, 101 patients underwent distal pancreatectomy (DP) for pancreatic cancer: 65 patients underwent standard-DP and 36 extended-DP, including the resection of the partial stomach (n = 12), adrenal gland (n = 7), liver (n = 7), colon (n = 8), celiac axis (n = 6), portal vein (n = 5), jejunum (n = 4) and kidney (n = 4). The two groups were compared in terms of their TNM classification, pathological grade, nodal status, state of resection margins, age, sex and levels of preoperative serum carbohydrate antigen 19-9 (CA 19.9). The morbidity and mortality were not statistically different in the two groups. The two groups disease-free and overall survival rates were significantly influenced by the tumor's stage, nodal status, pathological features and resection margins. Survival was not influenced by the extent of the surgical resection. However, when patients were stratified according to the type of extended resection, survival was worse in the group of patients undergoing vascular resection. Multivariate analysis showed that the stage and resection margins are independent predictors of disease-free and overall survival. Extended distal pancreatectomy may be performed with acceptable morbidity and mortality rates. Survival is not significantly different after standard or extended resection. However, the rate of tumor recurrence is high, and long-term survival is a rare event, especially in those patients who undergo distal pancreatectomy associated with vascular resection.

Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma.

Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.

ASO Visual Abstract: A Novel Criterion for Lymph Node Dissection in Distal Pancreatectomy for Ductal Adenocarcinoma: A Population Study of the U.S. SEER Database

ASO Visual Abstract: A Novel Criterion for Lymph Node Dissection in Distal Pancreatectomy for Ductal Adenocarcinoma: A Population Study of the U.S. SEER Database

ASO Author Reflections: Lymphadenectomy in Distal Pancreatectomy for Ductal Adenocarcinoma: How to Do Better?

ASO Author Reflections: Lymphadenectomy in Distal Pancreatectomy for Ductal Adenocarcinoma: How to Do Better?

ASO Visual Abstract: Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

ASO Visual Abstract: Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

BackgroundResection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC.MethodsPatients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004–2014) and standardized (period 2: 2015–2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance.ResultsLaparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p < 0.001) and anterior pancreatic surface (based on a 0 mm clearance; 18.9 vs. 35.4%, p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort.ConclusionsPathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis.

Prognostic impact of resection margin status in distal pancreatectomy for ductal adenocarcinoma

Purpose: Resection margin status is considered one of the few surgeon-controlled parameters affecting the prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC. Method: Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n=124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004-2014) and standardized (period 2: 2015-2020). Microscopic margin involvement (R1) was defined as ≤ 1mm clearance. Result: Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1-rate for the entire cohort was 73.4% having increased from 60.4% in period 1 to 83.1% in period 2 (p=0.005). The R1-rate significantly increased specifically for the posterior margin (35.8 vs 70.4%, p<0.001) and anterior pancreatic surface (based on 0 mm clearance; 18.9 vs 35.4%, p=0.045). Pathology examination period, poorly differentiated PDAC and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion and adjuvant chemotherapy but not R1 were significant prognostic factors for overall survival in the entire cohort. Conclusion: Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1-rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis.

ASO Author Reflections: Exploring the Oncologic Impact of Pancreatic Fistula after Distal Pancreatectomy for Ductal Adenocarcinoma.

ASO Author Reflections: Exploring the Oncologic Impact of Pancreatic Fistula after Distal Pancreatectomy for Ductal Adenocarcinoma.

Laparoscopic extended versus open extended distal pancreatectomy for ductal adenocarcinoma: A pan-European propensity-score matched study

Laparoscopic extended versus open extended distal pancreatectomy for ductal adenocarcinoma: A pan-European propensity-score matched study

Robotic vs. laparoscopic distal pancreatectomy—equipoise in current clinical practice?

Since the first reports of minimally invasive distal pancreatectomy 25 years ago (1), widespread adoption into routine clinical practice has been slow (2), largely due to limited formal training opportunities, concerns surrounding oncological safety and the lack of randomised controlled trial data (3). The recent pan-European Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA) study incorporated 1,212 patients from 34 centres with a propensity-matched study design to demonstrate comparable survival and post-operative complication rates between the minimally-invasive vs . open groups (4). However, oncological outcome parameters were contradictory (with a minimally-invasive approach associated with higher R0 resection rates, but lower Gerota’s fascia resection and lymph node yields), strengthening the case for high quality randomised controlled trials in this setting (5). Further, of the 356 minimally invasive distal pancreatectomies included in the DIPLOMA study, only 16 (4%) were performed robotically. Robust evidence to support the theoretical benefits of robotic assistance in facilitating a safe and effective minimally invasive approach to distal pancreatectomy is currently lacking.

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study

Background: A recent survey revealed that many European surgeons have concerns about the oncological safety of minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC). Methods: A pan-European retrospective cohort study was performed on patients who underwent MIDP or open distal pancreatectomy (ODP) for PDAC (2007-2015). MIDP patients were matched to ODP patients (1:1) based on propensity scores obtained via multivariable logistic regression including only preoperatively variables: sex, age, BMI, ASA, prior abdominal surgery, surgery year, tumor location and size. Primary outcome was radical (R0) resection rate. Results: In total, 1336 patients were included from 33 centers in 11 countries. Mortality was 2% and median survival 29 months. Of 369(28%) MIDP patients, 239 could be matched to an ODP patient. Conversion rate was 21%(n=44). After matching, R0 resection rate was 66%(n=149) for MIDP vs 52%(n=119) for ODP (p=0.002), lymph node retrieval was 13(IQR=7-23) vs 19(IQR=12-26)(p<0.001), the use of adjuvant chemotherapy was 72% vs 67% (p=0.28) and median overall survival (31 vs 26 months (p=0.51). Major complication rate (Clavien-Dindo 3-4) was 16%(n=36) vs 24%(n=53)(p=0.06), 90-day mortality 1%(n=2) vs 2%(n=4)(P=0.44) and hospital stay 7(IQR=5-10) vs 9(IQR=7-14) days (p<0.001). Conclusion: This pan-European propensity score matched analysis suggests short term benefits for MIDP over ODP. A randomized controlled trial is, however, needed to confirm the oncologic safety of MIDP for PDAC.

Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA)

The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC). Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC. This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival. In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss [200 mL (60-400) vs 300 mL (150-500), P = 0.001] and hospital stay [8 (6-12) vs 9 (7-14) days, P < 0.001] were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval [14 (8-22) vs 22 (14-31), P < 0.001] were lower after MIDP. Median overall survival was 28 [95% confidence interval (CI), 22-34] versus 31 (95% CI, 26-36) months (P = 0.929). Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA)-a difficult question to answer.

Since the introduction of laparoscopy as an adjunct to abdominal surgery in the 1980’s, surgeons have sought to compare the clinical outcomes of minimally invasive procedures with their parent operations.

Can standardized pathology examination increase the lymph node yield following laparoscopic distal pancreatectomy for ductal adenocarcinoma?

BackgroundLymph node yield (LNY) is an indicator of oncological adequacy of surgery in patients with pancreatic ductal adenocarcinoma (PDAC). Our hypothesis is that standardized pathology examination (SPE) aimed at accurate staging can increase the LNY without changing surgical technique. MethodsAfter the introduction of SPE for distal pancreatosplenectomy specimens at Oslo University Hospital, prospective data were collected on patients with PDAC undergoing laparoscopic distal pancreatosplenectomy (LDP). Their data were compared with retrospective data from specimens examined in a non-standardized way (NSPE). ResultsSPE and NSPE were applied to 20 and 33 specimens, respectively. SPE was associated with a higher LNY and a higher median number of positive lymph nodes (PLN) in the specimen (18 vs 7, P = 0.001 and 4 vs 1, P = 0.005, respectively). In the stepwise regression model, SPE and younger age resulted in an increased LNY. In the logistic regression model, increased LNY and larger tumor size positively correlated with the presence of PLN. ConclusionSPE of distal pancreatosplenectomy specimens is associated with higher LNY in patients with PDAC, which increases the likelihood of detecting PLN and reduces the risk of understaging. These findings also indicate that the LDP technique provides an adequate LNY in patients with PDAC.

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): A European propensity score matched study

Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): A European propensity score matched study

Is safe the laparoscopic approach in distal pancreatectomy for ductal adenocarcinoma? Systematic review and meta-analysis

Is safe the laparoscopic approach in distal pancreatectomy for ductal adenocarcinoma? Systematic review and meta-analysis

The laparoscopic approach to distal pancreatectomy for ductal adenocarcinoma results in shorter lengths of stay without compromising oncologic outcomes

BackgroundThe oncologic equivalence of laparoscopic distal pancreatectomy (LDP) to open pancreatectomy (ODP) for ductal adenocarcinoma (DAC) is not established. MethodsThe National Cancer Data Base was used to compare perioperative outcomes following LDP and ODP for DAC between 2010 and 2011. ResultsOne hundred forty-five patients underwent LDP; 625 underwent ODP. Compared with ODP, patients undergoing LDP were older (68 ± 10.1 vs 66 ± 10.5 years, P = .027), more likely treated in academic centers (70% vs 59%, P = .01), and had shorter hospital stays (6.8 ± 4.6 vs 8.9 ± 7.5 days, P < .001). Demographic data, lymph node count, 30-day unplanned readmission, and 30-day mortality were identical between groups. Multivariable regression identified a lower probability of prolonged length of stay with LDP (odds ratio .51, 95% confidence interval .327 to .785, P = .0023). There was no association between surgical approach and node count, readmission, or mortality. ConclusionLDP for DAC provides shorter postoperative lengths of stay and rates of readmission and 30-day mortality similar to OPD without compromising perioperative oncologic outcomes.

Comparative Effectiveness of Minimally Invasive and Open Distal Pancreatectomy for Ductal Adenocarcinoma

Multicenter studies indicate that outcomes of open (ODP) and minimally invasive distal pancreatectomy (MIDP) are equivalent for benign lesions. However, data for pancreatic carcinoma are limited. To compare outcomes of ODP and MIDP for early-stage pancreatic ductal carcinoma to determine relative safety and oncologic efficacy. Retrospective analysis of 62 consecutive patients undergoing ODP or MIDP for pancreatic ductal carcinoma by intention to treat with propensity scoring to correct for selection bias. A high-volume university center for pancreatic surgery. Sixty-two patients at a single institution. Patients underwent ODP or MIDP. Perioperative mortality, morbidity, readmission, postoperative complications, disease progression, and overall survival. Thirty-four patients underwent ODP, and 28 underwent MIDP with 5 conversions to ODP. No significant differences in age, body mass index, performance status, tumor size, or radiographic stage were identified. High rates of margin-negative resection (ODP, 88%; MIDP, 86%) and median lymph node clearance (ODP, 12; MIDP, 11) were achieved in both groups with equal rates and severity of postoperative complications (ODP, 50%; MIDP, 39%) and pancreatic fistula (ODP, 29%; MIDP, 21%). Despite conversions, intended MIDP was associated with reduced blood loss (P = .006) and length of stay (P = .04). Conversion was associated with a poor histologic grade and positive nodes. Median overall survival for the entire cohort was 19 (95% CI, 14-47) months. Minimally invasive distal pancreatectomy was performed increasingly in later study years and for patients with a higher Charlson-Age Comorbidity Index. Overall survival after ODP or intended MIDP was equivalent after adjusting for comorbidity and year of surgery (relative hazard, 1.11 [95% CI, 0.47-2.62]). We detected no evidence that MIDP was inferior to ODP based on postoperative outcomes or overall survival. This conclusion was verified by propensity score analysis with adjustment for factors affecting selection of operative technique.

Distal Pancreatectomy for Resectable Adenocarcinoma of the Body and Tail of the Pancreas

The study goal was to analyze outcome after distal pancreatectomy for three subtypes of adenocarcinoma to determine the role of en bloc resection in surgical management. A secondary aim was to identify those clinicopathologic factors correlating with survival in an analysis limited to ductal adenocarcinoma. Medical records of consecutive patients undergoing distal pancreatectomy for adenocarcinoma between 1987 and 2003 were reviewed. A comparative analysis was undertaken of the safety and outcome of patients undergoing standard and en bloc resections. Clinicopathologic factors for patients undergoing distal pancreatectomy for ductal adenocarcinoma were subjected to both univariate and multivariate survival analyses. Ninety-three patients underwent resection for ductal adenocarcinoma (66, 71%), mucinous cystadenocarcinoma (18, 19%), or adenocarcinoma associated with intraductal papillary mucinous neoplasm (IPMN) (9, 10%). En bloc resection was required in 33 (35%) patients. There was no operative mortality. Median survival was 15.5 months, 30.2 months, and 50.7 months for ductal adenocarcinoma, mucinous cystadenocarcinoma, and adenocarcinoma associated with IPMN, respectively. Patients undergoing en bloc resection had a higher overall complication rate, required more transfusions and more intensive care unit admissions, and had a higher rate of positive margins; however, there were no deaths. For ductal adenocarcinoma, tumor size greater than 3.5 cm, age greater than 60 years, and stage were factors that correlated with survival on a univariate analysis. None were significant on multivariate analysis. Four patients with ductal adenocarcinoma were actual 5-year survivors. While en bloc resections are associated with a higher rate of complications, the majority are self-limited and mortality is low. Resection, including adjacent organs, should be performed when appropriate. Long-term survival for patients with cystadenocarcinoma or IPMN-associated adenocarcinoma can be anticipated. While rare, long-term survival for patients with ductal adenocarcinoma after distal pancreatectomy can be achieved.