Pancreatoduodenectomy For Pancreatic Ductal Adenocarcinoma Research Articles

Impact on Long-term Survival of a Standardized Histopathological Protocol on the R1 Incidence in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is a pathology with a very poor prognostic, the only curative treatment option being surgery, in association with chemotherapy. This study aims to assess the influence that the use of a standardized pathology report after a pancreaticoduodenectomy (PD) has on the R1 margins rate and the impact that this has on long term survival. Material and Methods: We included 116 patients admitted to the Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor Cluj Napoca, who underwent PD for PDAC (Pancreatic Ductal Adenocarcinoma) between January 2012 and May 2017. We divided them in two groups: 59 patients for which a nonstandardized histopathological protocol was used and 57 patients for which a standardized protocol was implemented. We considered a margin to be R1 when there were tumor cells at ¤ 1 mm from the resection margin. Results: The R1 percentage in the first group of patients was of 39%, while the R1 resection rate in the second group was of 68.4%. The median survival rate was similar in the two groups, with no statistically significant difference between them, but in the prospective study when comparing R0 vs R1 margins there was a statistically differences in 5 year OS with a p-value = 0.03. Conclusion: The use of a standardized pathology report reveals a significant increase in R1 resection rates. Also study revealed not only increasing R1 incidence when using a standardized histopathology report, but also that those margins (R1) playing a determinant role in 5-year OS. The mesopancreas is the most frequently R1 resection margin.

Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis

BackgroundPostoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. MethodsAll patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014–2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. ResultsOverall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03–0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25–1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). ConclusionThis nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.

SP2.6 Histological TNM stage and five-year survival after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Abstract Aims Patients with a pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head may be offered pancreatoduodenectomy (PD) providing they are suitable candidates. Unfortunately, recurrence rates are high following this operation and few patients achieve long-term survival. This study aimed to investigate and quantify the relationship between histological tumour, node and metastasis stage, and five-year survival. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for malignancy (29 centres from 8 countries, n=1484). PDAC patients were grouped by their T stage, N stage and M stage, and five-year survival rates were compared using Fisher’s exact test. Results A total of 885 patients (59.6%) had PDAC confirmed histologically. Five-year survival was 57.4%, 46.0%, 17.0% and 32.0% in patients with T1, T2, T3 and T4 disease, respectively (unavailable: 7 patients). T1-2 patients (vs T3-4) had significantly higher rates of five-year survival (OR: 4.8, 95% CI: 3.3-7.0). N0 patients (vs N1-2) had significantly higher rates of five-year survival (OR: 4.5, 95% CI: 3.2-6.3). M0 patients (vs M1) also had higher five-year survival rates but this was not quite significant due to the small sample size of the M1 group (OR: 3.8, 25.7% vs 8.3%, p=0.06). Conclusion In our multicentre study of patients who underwent PD for PDAC, increasing T and N histological stages were found to correlate with reduced five-year survival. The figures provided can be used to guide the consenting process and predict outcomes in individual patients.

Oncological outcomes after pancreatoduodenectomy for pancreatic ductal adenocarcinoma in octogenarians: case-control study

Abstract Background By the end of this decade, 70 per cent of all diagnosed pancreatic ductal adenocarcinomas will be in the elderly. Surgical resection is the only curative option. In the elderly perioperative mortality is higher, while controversy still exists as to whether aggressive treatment offers any survival benefit. This study aimed to assess the oncological benefit of pancreatoduodenectomy in octogenarians with pancreatic ductal adenocarcinoma. Method Retrospective multicentre case-control study of octogenarians and younger controls who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma between 2008 and 2017. The primary endpoint was overall survival and the secondary endpoint was disease-free survival. Results Overall, 220 patients were included. Although the Charlson co-morbidity index was higher in octogenerians, Eastern Cooperative Oncology Group performance status, ASA and pathological parameters were comparable. Adjuvant therapy was more frequently delivered in the younger group (n = 80, 73 per cent versus n = 58, 53 per cent, P = 0.006). There was no significant difference between octogenarians and controls in overall survival (20 versus 29 months, P = 0.095) or disease-free survival (19 versus 22 months, P = 0.742). On multivariable analysis, age was not an independent predictor of either oncological outcome measured. Conclusion Octogenarians with pancreatic ductal adenocarcinoma of the head and uncinate process may benefit from comparable oncological outcomes to younger patients with surgical treatment. Due to the age- and disease-related frailty and co-morbidities, careful preoperative assessment and patient selection is of paramount importance.

Comment on: "Reassessment of the Optimal Number of Examined Lymph Nodes in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma".

We read with great interest the article by Malleo et al1 on the reassessment of the optimal examined lymph node (ELN) in pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Malleo et al1 suggested that 28 and 25 ELNs as the optimal and minimal cutpoints, respectively, significantly improved the detection of N2 disease. We highly appreciate the authors for this innovative statistical method and exciting finding. It is of great clinical significance and may aid in survival prediction and clinical decision-making. However, one of the study’s main points needs further discussion. This study by Malleo et al,1 to determine the optimal or minimal ELNs, was conducted in all patients and ignored the effect of T stage on the optimal ELNs. Current studies found that the optimal ELNs for accurate staging was associated with T stage. Hua et al2 confirmed that the optimal ELNs for the adequate staging of pancreatic cancer was related to the T stage and suggested that at least 16, 21, and 23 ELNs should be examined for T1, T2, and T3 pancreatic cancer, respectively. Similar conclusions were reached in studies of colon and thyroid cancers, strongly implying that the higher the T stage of the tumor, the greater the optimal or minimal ELNs required for accurate staging.3,4 By analyzing the data in Table 1, we found that the proportion of patients with N2 increased with advancing T stage: 35.0%, 51.0%, and 54.7% for T1, T2, and T3 patients (P < 0.001), respectively. Marchegiani et al5 also confirmed that larger pancreatic tumors were associated with more positive lymph nodes and higher lymph node ratios (P < 0.05). This strongly indicated that the risk of staging patients with N2 disease was associated with the T stage. In fact, adequate ELN not only improves the accuracy of lymph node staging but also increases the chance of eradicating isolated tumor cells and micrometastases. Specifically, surgeons may need to examine as many lymph nodes as possible to detect N2 disease and enhance the chance of eradicating isolated tumor cells and micro-metastases in T3 patients. Conversely, for T1 patients, examining more lymph nodes seems less important. Currently, precision medicine, which is based on individual diagnosis and treatment, is at the forefront of cancer research. It brings hope for improving the prognosis of pancreatic cancer. Blindly performing extended lymph node dissection does not improve the prognosis of patients with pancreatic cancer. Instead, extended lymphadenectomy is associated with increased morbidity, operating room time, and length of stay.6 With the advances in medical imaging technology, the T stage is easily obtained in preoperative imaging and may provide guidance on the extent of lymph node dissection. Therefore, optimal and minimal ELN based on the T stage can encourage surgeons to develop individualized lymph node dissection protocols rather than a one-size-fits-all approach, which is also consistent with the essence of precision medicine.

The impact of resection margin distance on survival and recurrence in pancreatic ductal adenocarcinoma in a retrospective cohort analysis.

The prognostic effect of resection margin status following pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) remains controversial, even with the implementation of standardized pathological assessment. We therefore investigated the impact of resection margin (RM) status and RM distance in curative resected PDAC on overall survival (OS), disease-free survival (DFS) and recurrence. 108 patients were retrieved from a prospectively maintained database of a certified pancreatic cancer center. Distribution and relationships between circumferential resection margin (CRM) involvement (CRM≤1mm; CRM>1mm; CRM≥2mm) and their prognostic impact on OS and DFS were assessed using Kaplan-Meier statistics and the Log-Rank test. Multivariate logistic regression was used explain the development of a recurrence 12 months after surgery. 63 out of 108 patients had medial RM and 32 posterior RM involvement. There was no significant difference in OS and DFS between CRM≤1mm and CRM>1mm resections. Clearance at the medial margin of ≥2mm had an impact on OS and DFS, (RM≥2mm vs. RM<2mm: median OS 29.8 vs 16.8 months, median DFS 19.6 vs. 10.3 months). Multivariate analysis demonstrated that age, medial RM ≥2mm, lymph node status and chemotherapy were prognostic factors for OS and DFS. Posterior RM had no influence on OS or DFS. Not all RM seem to have the same impact on OS and DFS, and a clearance of 1mm for definition of a negative RM (i.e. CRM>1mm) seems not sufficient. Future studies should include more patients to stratify for potential confounders we could not account for. This study was registered with the German Clinical Trials Registry (reference number DRKS0017425).

Prognostic value of preoperative CT scan derived body composition measures in resected pancreatic cancer

BackgroundIt remains unclear whether preoperative body composition may affect the prognosis of pancreatic cancer patients undergoing surgery. The aim of the present study was to assess the extent to which preoperative body composition impacts on postoperative complication severity and survival in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). MethodsA retrospective cohort study was performed on consecutive patients who underwent pancreatoduodenectomy with preoperative CT scan imaging available. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA), subcutaneous fat area and liver steatosis (LS) were assessed. Sarcopenic obesity was defined as a high VFA/TAMA ratio. Postoperative complication burden was evaluated with the comprehensive complication index (CCI). ResultsOverall, 371 patients were included in the study. At 90 days after surgery, 80 patients (22%) experienced severe complications. The median CCI was 20.9 (IQR 0–30). At multivariate linear regression analysis, preoperative biliary drainage, ASA score ≥3, fistula risk score and sarcopenic obesity (37% increase; 95%CI 0.06–0.74; p = 0.046) were associated to an increase in CCI. Patient characteristics associated to sarcopenic obesity were older age, male gender and preoperative LS. At a median follow-up of 25 months (IQR 18–49), median disease-free survival (DFS) was 19 months (IQR 15–22). At cox-regression analysis, only pathological features were associated with DFS, while LS and other body composition measures did not show any prognostic role. ConclusionThe combination of sarcopenia and visceral obesity was significantly associated with increased complication severity after pancreatoduodenectomy for cancer. Patients’ body composition did not affect disease free survival after pancreatic cancer surgery.

Oncological Impact of Portal Vein Resection during Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Multicentric Retrospective Study from the RAW Study Group

Oncological Impact of Portal Vein Resection during Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Multicentric Retrospective Study from the RAW Study Group

Minimally Invasive versus Open Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Individual Patient Data Meta-analysis of Randomized Trials

Minimally Invasive versus Open Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Individual Patient Data Meta-analysis of Randomized Trials

HPB P03 Oncological outcomes are comparable between octogenarians and younger patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Abstract Background Oncological outcomes are comparable between octogenarians and younger patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma Methods A multicentre case-control study of octogenarians matched on complexity of surgery with consecutive younger controls who underwent PD for PDAC (2008–2017). Results Some 220 patients were included, 110 octogenarians (age 81 (80–83)) and 110 controls (age 69 (62–74)). Charlson Comorbidity Index score was higher in octogenarians than controls (7 (6–8) vs 5 (4–6)), p&amp;lt;0.0001) but Eastern Cooperative Oncology Group performance status (Groups 0–1: 99 vs 98; 2–3: 5 vs 4, p=0.756) and ASA (ASA 1–2: 72 vs 77; 3–4: 20 vs 18; p=0.635) were comparable. Adjuvant therapy was delivered more commonly in the younger cohort (76.2 vs 58.0%, p= 0.007). Tumour stage, lymph node ratio and resection margin status were comparable between groups. There was no difference between octogenarians and controls in OS (20 (14–26) vs 29, (24–24) months p=0.095) or DFS (19,(13–24) vs 22,(15–29) months p=0.742). On multivariate analysis, age was not a risk predictor. Conclusions In selected fit octogenarians, equivalent survival is achievable. Centralisation and multimodal therapy are key. Pre-operative risk stratification using at ECOG and albumin level can be used to identify an appropriate population.

HPB P65 Resection margin status and five-year survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Abstract Background Fit patients with a resectable cancer affecting the pancreatic head may be offered pancreatoduodenectomy (PD). Although this remains the only curative intent treatment option, few patients achieve long-term survival as early disease recurrence is common. This study aimed to investigate the correlation between resection margin status and five-year survival in PD patients whose postoperative histology confirmed pancreatic ductal adenocarcinoma (PDAC). Methods Data was extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective cohort study of outcomes following PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1,484). Patients with postoperative histology suggestive of PDAC were identified and compared to one another by their resection margin status. Five-year survival rates were compared using Fisher's exact test. Results A total of 885 patients had PDAC (59.6%) and 798 of these (90.2%) had resection margin data available. Of these, 393 (49.2%) had no positive margins (R0), 403 (50.5%) had at least one positive resection margin (R1), and 27 (3.4%) had an incomplete resection where tumour was knowingly left in situ at the time of surgery (R2). Five-year survival was 30.0%, 16.9% and 14.8% in those with R0, R1 and R2 disease, respectively. Patients with R0 disease had significantly higher five-year survival compared to those with R1-2 disease (30.0% vs 16.7%, p&amp;lt;0.00001). Conclusions In our multicentre international study of PD patients, almost half of all those with PDAC had no positive resection margins. Whilst these patients had improved outcomes compared to those with at least one positive margin, less than a third achieved five-year survival.

Delayed gastric emptying does not influence cancer-specific survival after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Delayed gastric emptying does not influence cancer-specific survival after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Long-term outcomes of standard versus extended lymphadenectomy in pancreatoduodenectomy for pancreatic ductal adenocarcinoma: A Chinese multi-center prospective randomized controlled trial

IntroductionThe value of extended lymphadenectomy in pancreatoduodenectomy (PD) has been discussed by five randomized controlled studies. However, the limitations in the studies made their conclusions not sufficiently reliable. ObjectivesThis multi-center randomized controlled study was designed to clarify the efficacy of extended lymphadenectomy in PD for pancreatic ductal adenocarcinoma (PDAC). MethodsFrom December 2016 to October 2018, 170 consecutive patients undergoing PD were enrolled and randomized to standard or extended lymphadenectomy for the treatment of PDAC from three high-volume institutions in China. Demographic, pathological characteristics and survival data of these patients were collected and analyzed. No neoadjuvant treatment was performed. The primary endpoint was the 3-year overall survival. ResultsFor all patients, the 3-year survival rate was 25.88 %. There was no between-group difference in 3-year survival rate (27.16 % vs 24.72 % p = 0.717). The median survival time for the standard group was 18 months, while for the extended group it was 15 months. The demographic and pathological characteristics were similar between groups. More positive lymph nodes could be found in the extended group (2.34 ± 3.46 vs 1.41 ± 2.12, p = 0.035), which led to nodule stage migration. All patients received chemotherapy. But patients in extended group were more likely to fail in completion of all-cycles chemotherapy before recurrence (31.46 % vs 17.28 %, p = 0.032). Incomplete chemotherapy before recurrence, higher N status and abnormal CA125 were independent risk factors for 1-year survival (p < 0.001, 95 % CI 0.076–0.368; p = 0.017, 95 % CI 1.113–3.021; p = 0.021, 95 % CI 1.136–4.960, respectively), which was higher in the standard group (75.31 % vs 58.43 %, p = 0.020). ConclusionThe extended lymphadenectomy in PD did not improve the long-term survival in patients with PDAC. Patients with extended lymphadenectomy had a worse 1-year overall survival. However, the nodule stage migration facilitated by the extended lymphadenectomy contributed to the precise tumor staging.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer.

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

Delayed Gastric Emptying Does Not Influence Cancer-Specific Survival after Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Background: Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD). The present study investigates the influence of delayed gastric emptying on cancer-specific survival after PD. Methods: We included 267 patients who underwent PD between 2014 and 2021. They were analyzed regarding demographic factors, pre- and perioperative characteristics, surgical complications, and long-term survival. Results: Patients with a higher Charlson Comorbidity Index (CCI) or pre-existing pulmonary disease suffered significantly more from DGE. When experiencing PPH, a prolonged hospital stay, or major overall complications (Clavien-Dindo °III-V) were more common in the DGE group. Tumor size over 3 cm negatively affected survival. Conclusions: DGE has no influence on long-term survival in PDAC patients, although it prolongs hospital stay.

External validation of three lymph node ratio-based nomograms predicting survival using an international cohort of patients with resected pancreatic head ductal adenocarcinoma

IntroductionLymph node ratio (LNR) is an important prognostic factor of survival in patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to validate three LNR-based nomograms using an international cohort. Materials and methodsConsecutive PDAC patients who underwent upfront pancreatoduodenectomy from six centers (Europe/USA) were collected (2000–2017). Patients with metastases, R2 resection, missing LNR data, and who died within 90 postoperative days were excluded. The updated Amsterdam nomogram, the nomogram by Pu et al., and the nomogram by Li et al. were selected. For the validation, calibration, discrimination capacity, and clinical utility were assessed. ResultsAfter exclusion of 176 patients, 1′113 patients were included. Median overall survival (OS) of the cohort was 23 months (95% CI: 21–25).For the three nomograms, Kaplan-Meier curves showed significant OS diminution with increasing scores (p < 0.01). All nomograms showed good calibration (non-significant Hosmer-Lemeshow tests). For the Amsterdam nomogram, area under the ROC curve (AUROC) for 3-year OS was 0.64 and 0.67 for 5-year OS. Sensitivity and specificity for 3-year OS prediction were 65% and 59%. Regarding the nomogram by Pu et al., AUROC for 3- and 5-year OS were 0.66 and 0.70. Sensitivity and specificity for 3-year OS prediction were 68% and 53%. For the Li nomogram, AUROC for 3- and 5-year OS were 0.67 and 0.71, while sensitivity and specificity for 3-year OS prediction were 63% and 60%. ConclusionThe three nomograms were validated using an international cohort. Those nomograms can be used in clinical practice to evaluate survival after pancreatoduodenectomy for PDAC.

Impact of the aberrant right hepatic artery on local recurrence of pancreatic ductal adenocarcinoma after pancreaticoduodenectomy

BackgroundThe influence and risk associated with an aberrant right hepatic artery, a common anatomical variation, during pancreatoduodenectomy for pancreatic ductal adenocarcinoma has not been fully investigated. The present study analyzed the impact of an aberrant right hepatic artery on local recurrence after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. MethodsA total of 169 patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy at 2 separate Japanese medical institutions were retrospectively analyzed. ResultsThirty of 169 patients (17.7%) presented with an aberrant right hepatic artery. The incidence of local recurrence was higher in the aberrant right hepatic artery group than in the normal right hepatic artery group (43.3 vs 21.5%, P = .017). The local recurrence-free survival was significantly poorer in the aberrant right hepatic artery group than in the normal right hepatic artery group (P = .011). A multivariate analysis found that the aberrant right hepatic artery was an independent risk factor for local recurrence (hazard ratio: 3.74, P = .017). In the aberrant right hepatic artery group, more frequent local recurrence was observed in patients with tumors situated ≤10 mm from the aberrant right hepatic artery root. However, local recurrence was not observed in 2 out of 3 patients with tumors ≤10 mm from the aberrant right hepatic artery root who underwent pancreatoduodenectomy with combined resection of the aberrant right hepatic artery. ConclusionThe presence of an aberrant right hepatic artery in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma may be associated with an increased risk of postoperative local recurrence. Combined resection of the aberrant right hepatic artery may reduce local recurrence, especially for tumors near the root of the aberrant right hepatic artery.

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.

Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective, Lymphadenectomy Protocol.

BackgroundImplementing a prospective lymphadenectomy protocol, we investigated the nodal yields and metastases per anatomical stations and nodal echelon following upfront pancreatoduodenectomy (PD) for cancer. Next, the relationship between the extension of nodal dissection, the number of examined and positive nodes (ELN/PLN), disease staging and prognosis was assessed.MethodsLymphadenectomy included stations 5, 6, 8a-p, 12a-b-p, 13, 14a-b, 17, and jejunal mesentery nodes. Data were stratified by N-status, anatomical stations, and nodal echelons. First echelon was defined as stations embedded in the main specimen and second echelon as stations sampled as separate specimens. Recurrence and survival analyses were performed by using standard statistics.ResultsOverall, 424 patients were enrolled from June 2013 through December 2018. The median number of ELN and PLN was 42 (interquartile range [IQR] 34-50) and 4 (IQR 2-8). Node-positive patients were 88.2%. The commonest metastatic sites were stations 13 (77.8%) and 14 (57.5%). The median number of ELN and PLN in the first echelon was 28 (IQR 23-34) and 4 (IQR 1-7). While first-echelon dissection provided enough ELN for optimal nodal staging, the aggregate rate of second-echelon metastases approached 30%. Nodal-related factors associated with recurrence and survival were N-status, multiple metastatic stations, metastases to station 14, and jejunal mesentery nodes.ConclusionsFirst-echelon dissection provides adequate number of ELN for optimal staging. Nodal metastases occur mostly at stations 13/14, although second-echelon involvement is frequent. Only station 14 and jejunal mesentery nodes involvement was prognostically relevant. This latter station should be included in the standard nodal map and analyzed pathologically.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-022-11417-3.

Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective Lymphadenectomy Protocol

Introduction: The issue of nodal metastases location in upfront pancreatoduodenectomy (PD) for cancer is unclear. Implementing a prospective lymphadenectomy protocol, we investigated the nodal yields and metastases per anatomical stations and nodal echelon. Next, the relationship between the extension of nodal dissection, the number of examined/positive nodes (ELN/PLN), disease staging and prognosis was assessed. Methods: Lymphadenectomy included stations 5/6/8a-p/12a-b-c-p/13/14a-b/17 and jejunal mesentery nodes. Stations embedded in the specimen (13/14/17/jejunal mesentery) were defined as first-echelon, those sampled separately (5/6/8/12) as second-echelon. Recurrence and survival were analyzed. Results: Overall, 424 PDs (2013-2018) were enrolled. The median number of ELN and PLN was 42 (IQR 34-50) and 4 (IQR 2-8). Node-positive patients were 88.2%. The commonest metastatic sites were stations 13 (77.8%) and 14 (57.5%). Overall, 248 patients (58.5%) had metastases only in the first echelon, 4 (0.9%) only in the second, 122 (28.8%) in both. The median number of ELN and PLN in the first echelon was 28 and 4. Second-echelon nodes increased nodal counts by 10 ELN and 0 PLN, translating in only minor changes in staging. Nodal-related factors independently associated with recurrence and survival were N-status, multiple metastatic stations, metastases to station 14 and jejunal mesentery nodes (Table). The highest concordance was reached when including metastases location (c-index=0.769). Conclusion: First-echelon dissection provides an adequate number of ELN for optimal staging. Nodal metastases occur mostly at stations 13/14, although second-echelon involvement is frequent. Station 14 and jejunal mesentery nodes involvement is prognostically relevant. They should be included in the standard nodal map and analyzed pathologically.