Pancreaticoduodenectomy For Pancreatic Adenocarcinoma Research Articles

Five-year recurrence/survival after pancreatoduodenectomy for pancreatic adenocarcinoma: does pre-existing diabetes matter? Results from the Recurrence After Whipple's (RAW) study

ObjectivesDiabetes mellitus (DM) has a complex relationship with pancreatic cancer. This study examines the impact of preoperative DM, both recent-onset and pre-existing, on long-term outcomes following pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). MethodsData were extracted from the Recurrence After Whipple's (RAW) study, a multi-centre cohort of PD performed for pancreatic head malignancy (2012–2015). Recurrence and five-year survival rates of patients with DM were compared to those without. A subgroup analysis was also performed to compare patients with recent-onset DM (less than one year) to patients with established DM. ResultsOut of 758 patients that were included, 187 (24.7%) had DM, of whom, 47 of the 187 (25.1%) had recent-onset DM. There was no difference in the rate of postoperative pancreatic fistula (DM: 5.9% vs no DM 9.8%; p = 0.11), five-year survival (DM: 24.1% vs no DM: 22.9%; p = 0.77) or five-year recurrence (DM: 71.7% vs no DM: 67.4%; p = 0.32). There was also no difference between patients with recent-onset DM and patients with established DM in postoperative outcomes, recurrence, or survival. ConclusionsWe found no difference in five-year recurrence and survival between diabetic patients and those without diabetes. Patients with pre-existing DM should be evaluated for PD on a comparable basis to non-diabetic patients.

Preoperative CA19.9 level predicts lymph node metastasis in resectable adenocarcinoma of the head of the pancreas: A further plea for biological resectability criteria.

Lymph-nodal involvement (N+) represents an adverse prognostic factor after pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Preoperative diagnostic and staging modalities lack sensitivity for identifying N+. This study aimed to investigate preoperative CA19.9 in predicting the N+ stage in resectable-PDAC (R-PDAC). Patients included in a multi-institutional retrospective database of PDs performed for R-PDAC from January 2000 to June 2021 were analyzed. A preoperative laboratory value of CA19.9 >37U/L was used in univariate and multivariate logistic regression analysis to determine a possible association with N+. Additionally, different cut-offs of CA19.9 related to the preoperative clinical T (cT) stage was assessed to evaluate the risk of N+. A total of 2034 PDs from thirteen centers were included in the study. CA19.9>37U/L was significantly associated with higher N+ at univariate and multivariate analysis (P<0.001). CA19.9 levels >37U/L were associated with N+ in 75.9%, 81.3%, and 85.7% of patients, respectively, in cT1, cT2, and cT3 tumors and with higher cut-off values for all cT stages. Lymph nodal involvement is strongly related to preoperative CA19.9 levels. Specially in patients staged as cT3 the CA 19.9 could represent a valid and easy tool to suspect nodal involvement. Due to these findings, R-PDAC patients with elevated CA19.9 values should be considered in a more biologically advanced stage.

Major Postoperative Complications Limit Adjuvant Therapy Administration in Patients Undergoing Pancreatoduodenectomy for Distal Cholangiocarcinoma or Pancreatic Ductal Adenocarcinoma.

Guidelines for perioperative systemic therapy administration in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma (PDAC) and distal cholangiocarcinoma (dCCA) are evolving. Decisions regarding adjuvant therapy are influenced by postoperative morbidity, which is common after pancreatoduodenectomy. We evaluated whether postoperative complications are associated with receipt of adjuvant therapy after pancreatoduodenectomy. A retrospective analysis of patients undergoing pancreatoduodenectomy for PDAC or dCCA from 2015 to 2020 was conducted. Demographic, clinicopathologic, and postoperative variables were analyzed. Overall, 186 patients were included-145 with PDAC and 41 with dCCA. Postoperative complication rates were similar for both pathologies (61% and 66% for PDAC and dCCA, respectively). Major postoperative complications (MPCs), defined as Clavien-Dindo >3, occurred in 15% and 24% of PDAC and dCCA patients, respectively. Patients with MPCs received lower rates of adjuvant therapy administration, irrespective of primary tumor (PDAC: 21 vs. 72%, p=0.008; dCCA: 20 vs. 58%, p=0.065). Recurrence-free survival (RFS) was worse for patients with PDAC who experienced an MPC [8 months (interquartile range [IQR] 1-15) vs. 23 months (IQR 19-27), p<0.001] or who did not receive any perioperative systemic therapy [11 months (IQR 7-15) vs. 23 months (IQR 18-29), p=0.038]. In patients with dCCA, 1-year RFS was worse for patients who did not receive adjuvant therapy (55 vs. 77%, p=0.038). Patients who underwent pancreatoduodenectomy for either PDAC or dCCA and who experienced an MPC had lower rates of adjuvant therapy and worse RFS, suggesting that clinicians adopt a standard neoadjuvant systemic therapy strategy in patients with PDAC. Our results propose a paradigm shift towards preoperative systemic therapy in patients with dCCA.

Implications of an isolated positive vascular groove after whipple for pancreatic adenocarcinoma

Background: The clinical significance of a positive vascular groove surface (pVG-R1: tumor < 1mm from VG surface) following pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) remains debated. The College of American Pathologists no longer considers the VG a resection margin but rather a surface that is covered in-vivo by the superior mesenteric vein (SMV) up to the portal vein confluence. We aim to evaluate the impact on the overall survival of a pVG-R1 when all other margins of resection are negative following PD.

Impact of Grade B and C Postoperative Pancreatic Fistula on Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Impact of Grade B and C Postoperative Pancreatic Fistula on Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Surgical Approach does not Affect Return to Intended Oncologic Therapy Following Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: A Propensity-Matched Study.

The effect of minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic pancreaticoduodenectomy (LPD and RPD, respectively), on compliance and time to return to intended oncologic therapy (RIOT) for pancreatic ductal adenocarcinoma (PDAC) remains unknown. Patients with nonmetastatic PDAC were analyzed in the National Cancer Database (NCDB). Three groups were matched per propensity score: open pancreaticoduodenectomy (OPD) and MIPD, LPD and RPD, and converted and nonconverted patients. RIOT rates and time to RIOT were examined. A total of 14,135 patients were included: 11,834 (83.7%) underwent OPD and 2301 (16.3%) underwent MIPD. After score matching, RIOT rates (67.2 vs. 65.3%; p = 0.112) and RIOT within 8 weeks (57.7 vs. 56.4%; p = 0.276) were similar among MIPD and OPD groups, and approach was not a significant predictor of RIOT on multivariable regression. Neither RIOT nor time to RIOT were different among LPD and RPD groups (63.9 vs. 67.0%, and 58.4 vs. 56.9%, respectively). Compared with LPD, RPD was associated with lower conversion rates (HR 0.519; p < 0.001), and conversion was associated with longer median time to RIOT (10 vs. 8 weeks; p = 0.041). In this national cohort, approach did not impact RIOT rates or time to RIOT for patients with PDAC. While conversion was associated with longer median time to RIOT, readiness to commence adjuvant therapy was similar for LPD and RPD.

Intraoperative Pancreatic Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in the Era of Neoadjuvant Therapy: A Multi-institutional Analysis from the Central Pancreatic Consortium.

Data regarding the survival impact of converting frozen-section (FS):R1 pancreatic neck margins to permanent section (PS):R0 by additional resection (i.e., converted-R0) during upfront pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) are conflicting. The impact of neoadjuvant therapy on this practice and its relationship with overall survival (OS) is incompletely understood. We reviewed PDAC patients (80% borderline resectable/locally advanced [BR/LA]) undergoing pancreaticoduodenectomy after neoadjuvant therapy at seven, academic, high-volume centers (2010-2018). Multivariable models examined the association of PS:R0, PS:R1, and converted-R0 margins with OS. Of 272 patients receiving at least 2 (median 4) cycles of neoadjuvant chemotherapy (71% mFOLFIRINOX or gemcitabine/nab-paclitaxel) and undergoing pancreaticoduodenectomy with intraoperative frozen-section assessment of the transected pancreatic neck margin, PS:R0 (n=220, 80.9%) was observed in a majority of patients; 18 patients (6.6%) had converted-R0 margins following additional resection, whereas 34 patients (12.5%) had persistently positive PS:R1 margins. At a median follow-up of 42 months, PS:R0 resection was associated with improved OS compared with either converted-R0 or PS:R1 resection (median 25 vs. 14 vs. 16 months, respectively; p=0.023), with no survival difference between the converted-R0 and PS:R1 groups (p=0.9). On Cox regression, SMA margin positivity (hazard ratio 2.2, p=0.012), but not neck margin positivity (hazard ratio 1.2, p=0.65), was associated with worse OS. In this multi-institutional cohort of predominantly BR/LA PDAC patients undergoing pancreaticoduodenectomy following modern neoadjuvant therapy, pursuing a negative neck margin intraoperatively if the initial margin is positive does not appear to be associated with improved survival.

Response to the comment of V. Vashney and A. Swami for “pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma”

We appreciate the interest of Vashney and Swami1 for our recent retrospective bi-centric study on pre-operative embolization (PEA) of a replaced right hepatic artery (rRHA) before pancreaticoduodenectomy (PD)2 although we didn't agree with all their remarks or suggestions.

Role of biliary drainage before pancreatoduodenectomy for pancreatic adenocarcinoma: a retrospective study.

Utilization of preoperative biliary drainage prior to pancreatoduodenectomy for patients with pancreatic ductal adenocarcinoma and obstructive jaundice remains controversial. All patients that underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma at the authors' institution were analyzed retrospectively to evaluate the effect of endoscopic biliary drainage on postoperative outcomes and long-term survival. Age, gender, ASA-Score, operative time, blood loss, intraoperative transfusion rate, and postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, bleeding, bile fistula, wound infections, sepsis, pulmonary and cardiac complications as well as the need for relaparotomy were analyzed. Two hundred eighty-five patients with similar baseline characteristics underwent pancreatoduodenectomy, 151 patients with biliary drainage (group 1) and 134 without drainage (group 2). More than 60% of patients had one or more postoperative complications, without significant difference between the two groups (P=0.140). The overall incidence of pancreatic fistula was 21.75% in both groups (group 1: 19.87% vs. group 2: 23.88%, P=0.659). Wound healing impairment was the only postoperative complication that differed significantly between the two groups (group 1: 24.50% vs. group 2: 8.96%, P<0.001). In multivariate risk analysis, biliary drainage was the only independent risk factor for wound healing impairment (OR 4.126; 95% CI: 1.295-13.143; P=0.017). The median overall survival was similar in both groups. Preoperative endoscopic biliary drainage is associated with an increased risk for wound healing impairment and wound infections. Therefore, biliary drainage should not be used routinely in patients with obstructive jaundice prior to pancreatoduodenectomy.

Contemporary Assessment of Need for Palliative Bypass After Aborted Pancreatoduodenectomy Following Neoadjuvant Therapy

BackgroundPlanned pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) can be aborted due to intraoperative findings. There is little guidance regarding the need for prophylactic bypass following an aborted PD to prevent symptomatic biliary obstruction or gastric outlet obstruction (GOO) postoperatively. The aim of this study was to characterize postoperative interventions and postsurgical survival in patients following aborted PD. MethodsPatients with PDAC treated with neoadjuvant therapy and staging laparoscopy prior to planned PD between 2010 and 2015 were reviewed for aborted PDs. Data on postoperative biliary obstruction, GOO, procedural intervention, and postsurgical survival were analyzed. ResultsOf 271 planned PDs, 47 (17.3%) were aborted. Thirty-six patients had ≥ 2 months of follow-up data and were included. Six patients underwent hepaticojejunostomy and nine patients underwent gastrojejunostomy at the time of the aborted PD. Sixteen of 30 patients (53%) without a surgical biliary bypass required endoscopic intervention, but none required palliative surgery. Ten of 27 patients (37%) without an operative gastrojejunostomy required intervention, but none required palliative surgery. Endoscopic or percutaneous therapy was required to treat 13/16 (81%) patients who presented with postoperative biliary obstructions and 6/10 (60%) of GOOs. Median survival following aborted PD was 13.3 months (CI 8.9–17.7). There were no differences in survival when comparing patients who developed a biliary obstruction (p = 0.92) or GOO (p = 0.90) to asymptomatic patients. ConclusionsFollowing aborted PD, patients commonly develop obstructive symptoms. However, these symptoms can generally be managed without surgical intervention. In asymptomatic patients, preemptive surgical bypasses are not required at the time of aborted PD.

Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer

Background: The aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines. Methods: A retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS). Results: 114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P=0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P=0.471) but in the PD group (R0 23 vs. R1 14 months, P=0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis. Conclusion: PDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.

Trends in outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma from 2005-2016: improvement has unfortunately not been uniform across hospitals

Presenter: Christopher T Aquina MD, MPH | The Ohio State University Background: A “textbook oncologic outcome” (TOO) is a composite measure representing the “ideal” outcome for patients undergoing cancer surgery. Although operative technique for pancreaticoduodenectomy for PDAC has improved, the impact on TOO is unknown. We assessed national trends in TOO and 1-year mortality following pancreaticoduodenectomy for PDAC. Methods: Patients who underwent curative-intent pancreaticoduodenectomy for PDAC were identified within the National Cancer Database (2005-2016). TOO was defined as: adequate lymph node yield (≥12), R0 resection, non-length of stay (LOS) outlier ( < 25 days), no hospital readmission, no 90-day mortality, and receipt of chemotherapy. Trends in outcome measures (2005-2007 vs. 2014-2016), TOO, and 1-year mortality were compared using bivariate and mixed-effects analyses. Results: Among 40,342 patients, there was significant improvement in all outcome measures except rate of readmission (adequate lymph node yield: 49.1%->76.7%; R0 resection: 75.6%->78.8%; LOS outlier: 8.9%->5.2%; 90-day mortality: 7.6%->5.5%; chemotherapy receipt: 59.2%->76.4%; TOO: 16.3%->34.3%; 1-year mortality: 34.8%->28.6%) (all p<0.001). Across 418 hospitals, wide variation was present in baseline risk-adjusted rates of TOO (median = 15.7%, range = 6.9%-50.8%) and 1-year mortality (median = 32.9%, range = 17.1%-49.8%) during 2005-2007. Wide hospital-level variation was also present in the degree of improvement in adjusted TOO (OR range = 0.67-8.32) and 1-year mortality (OR range = 0.44-2.05) over time. High hospital volume (≥20 pancreatic cancer resections/year) was the only hospital factor associated with greater improvement in adjusted TOO (median OR: 3.23 vs 2.69, p<0.001) and 1-year mortality (median OR: 0.75 vs 0.83, p = 0.006). Conclusion: There have been significant improvements in outcomes following pancreaticoduodenectomy for PDAC. However, wide variation in outcomes and improvement persists across hospitals, particularly among low-volume hospitals.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma

BackgroundAdjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma. MethodsPatients with stage I-III pancreatic head adenocarcinoma in the 2006–2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6–12-weeks, and 12–24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy. ResultsOf 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6–12 weeks, and 1194 (8.9%) within 12–24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6–12-weeks: 0.744, and 12–24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens. ConclusionsFor patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.

Is the Involvement of the Hepatic Artery Lymph Node a Poor Prognostic Factor in Pancreatic Adenocarcinoma?

IntroductionThe aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). MethodsA single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN− (peripancreatic lymph node)/HALN−, PPLN+/HALN− and PPLN+/HALN+. Survival analysis was estimated by the Kaplan–Meier method, and Cox regression was used for risk factors analyses. ResultsOut of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1–159months). HALN and PPLN were negative in 12patients (PPLN−/HALN−, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN−, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN−/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN−/HALN− group (82%, 72%, 54%) than in the PPLN+/HALN− group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN−/HALN− group (18%, 46%, 55%) than in the PPLN+/HALN− group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. ConclusionsIn pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.

Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.

Composite outcomes may more accurately reflect patient and provider expectations around optimal care. We sought to determine the impact of achieving a so-called "textbook oncologic outcome" (TOO) among patients undergoing resection of pancreatic adenocarcinoma (PDAC). Patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2006 and 2016 were identified in the National Cancer Database (NCDB). TOO was defined by: margin negative resection, compliant lymph node evaluation, no prolonged length-of-stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Factors associated with TOO and overall survival (OS) were evaluated using multivariable logistic and Cox regression models, respectively. Among 18 608 patients who underwent PD at 782 hospitals, many patients successfully achieved certain TOO factors such as R0 margin (77.9%) and no 30-day mortality (96.9%), while other TOO criteria such as receipt of adjuvant therapy (48.2%) were achieved less frequently. Overall, only 3124 (16.8%) patients achieved a TOO. Factors associated with lower odds of TOO included: older age, Black race, Medicaid insurance, Community facility, and low PD facility (<20 PD/y) (all P < .05). Achievement of a TOO was associated with lower risk of mortality (HR 0.74; 95% CI, 0.70-0.77). While TOO was associated with improved long-term survival, TOO was only achieved in 16.8% of patients undergoing PD.

Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer

BackgroundThe aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines. MethodsA retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS). Results114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P = 0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P = 0.471) but in the PD group (R0 23 vs. R1 14 months, P = 0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis. ConclusionPDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.

¿Es realmente la afectación del ganglio de la arteria hepática un factor de mal pronóstico en el adenocarcinoma de páncreas?

IntroductionThe aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). MethodsA single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN− (peripancreatic lymph node)/HALN−, PPLN+/HALN− and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses. ResultsOut of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12patients (PPLN−/HALN−, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN−, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN−/HALN− group (82%, 72%, 54%) than in the PPLN+/HALN− group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN−/HALN− group (18%, 46%, 55%) than in the PPLN+/HALN− group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. ConclusionsIn pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.

Population-Level Symptom Assessment Following Pancreaticoduodenectomy for Adenocarcinoma

Postoperative morbidity associated with pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA) remains as high as 70%. However, to our knowledge, few studies have examined quality of life in this patient population. To identify symptom burden and trajectories and factors associated with high symptom burden following PD for PA. This population-based cohort study of patients undergoing PD for PA diagnosed between 2009 and 2015 linked population-level administrative health care data to routinely prospectively collected Edmonton Symptom Assessment System (ESAS) scores from 2009 to 2015, with a data analysis undertaken in 2018. Baseline characteristics, including age, sex, income quintile, rurality, immigration status, and comorbidity burden, as well as treatment characteristics, including year of surgery and receipt of chemotherapy. The outcome of interest was moderate to severe symptoms (defined as ESAS ≥4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and impaired well-being. The monthly prevalence of moderate to severe symptoms was presented graphically for each symptom. Multivariable regression models identified factors associated with the reporting of moderate to severe symptoms. We analyzed 6058 individual symptom assessments among 615 patients with PA who underwent resection (285 women [46.3%]) with ESAS data. Tiredness (443 [72%]), impaired well-being (418 [68%]), and lack of appetite (400 [65%]) were most commonly reported as moderate to severe. The proportion of patients with moderate to severe symptoms was highest immediately after surgery (range, 14%-66% per symptom) and decreased over time, stabilizing around 3 months (range, 8%-42% per symptom). Female sex, higher comorbidity, and lower income were associated with a higher risk of reporting moderate to severe symptoms. Receipt of adjuvant chemotherapy was not associated with the risk of moderate to severe symptoms. There is a high prevalence of symptoms following PD for PA, with improvement over the first 3 months following surgery. In what to our knowledge is the largest cohort reporting on symptom burden for this population, we have identified factors associated with symptom severity. These findings will aid in managing patients' perioperative expectations and designing strategies to improve targeted symptom management.

The Impact of the Depth of Venous Invasion on Survival Following Pancreatoduodenectomy for Pancreatic Cancer: a Meta-analysis of Available Evidence.

The prognostic significance of portal/superior mesenteric vein (PV/SMV) invasion at the time of pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) is contentious. The aim of this meta-analysis was to compare the survival outcomes in patients with histologically proven adventitial (superficial) versus media/intimal (deep) PV/SMV invasion at the time of PD for PDAC. A systematic search of the PubMed, MEDLINE and SCOPUS databases were performed in accordance with PRISMA guidelines. All articles reporting outcomes specific to the depth of PDAC invasion into the PV/SMV wall were included. The primary outcome measure was overall survival. Six studies including 310 patients who underwent pancreatic resection with PV/SMV resection for PDAC were included in this meta-analysis. There was no difference in overall survival comparing superficial vs deep invasion at 12months (64% vs 58% respectively, risk difference, - 0.09; CI, - 0.21-0.04; P = 0.183), 36months (22% vs 18% respectively, risk difference, - 0.05; CI, - 0.16-0.19; P = 0.857) and mean overall survival (42.8months vs 25.7months respectively, standard mean difference, - 0.27; CI, - 0.58, 0.03; P = 0.078). Although larger tumours were seen in those with confirmed deep vein wall invasion (P < 0.001), no difference was observed between the superficial and deep invasion groups with regard to age (P = 0.298), R1 resection (P = 0.896), nodal metastatic disease (P = 0.120) and perineural invasion (P = 0.609). This meta-analysis suggests that the depth of PV/SMV wall invasion by PDAC may not impact survival after PD. However, given the limited sample size, further research is warranted with homogenous cohorts and longer follow-up.