Extended pancreatectomy as defined by the ISGPS: useful in selected cases of pancreatic cancer but invaluable in other complex pancreatic tumors
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Extended pancreatectomy aimed at R0 resection of pancreatic tumors with adjacent vessel and organ involvement may be the only option for cure. This study was done with an objective to analyze the short- and long-term outcomes of extended pancreatic resections.
All pancreatectomies performed between 2006 and 2015 were included. The pancreatectomies were classified as standard or extended, as per the International Study Group for Pancreatic Surgery. All surgical complications and terminologies were according to Clavien-Dindo classification and International Study Group for Pancreatic Surgery guidelines. Morbidity and mortality were primary outcomes and disease-free survival was a secondary outcome.
Sixty-three extended and 620 standard pancreatectomies were performed. Major morbidity (Clavien grades III, IV and V) (37 vs. 29%, p = 0.21) and mortality (6 vs. 4%, p = 0.3) for extended pancreatectomies were comparable to those for standard pancreatectomies. Blood loss > 855 ml, need for blood transfusion, and tumor size were independent risk factors for morbidity, and the latter two for mortality. Standard pancreatectomies were associated with better 3-year disease-free survival than extended pancreatectomies (67 vs. 41%, p < 0.001). Extended pancreatectomies resulted in a significantly better median disease-free survival for non-pancreatic adenocarcinoma vs. pancreatic adenocarcinoma (33.3 vs. 9.5 months, p = 0.01).
Extended pancreatectomies resulted in similar peri-operative morbidity and mortality compared to standard pancreatectomies. Although the survival of patients undergoing these complex procedures is inferior to standard pancreatectomies, they should be undertaken not only in selected cases of pancreatic cancer but even more so in other complex pancreatic tumors.
KeywordsExtended Pancreatectomy Outcome Survival
Abhishek Mitra—acquisition of data, analysis, interpretation of data, drafting of manuscript, critical revision of manuscript; Esha Pai—acquisition of data, analysis, interpretation of data, drafting of manuscript; Priya Ranganathan—analysis and interpretation of data, critical revision of manuscript; Ashwin DeSouza—critical revision of manuscript; Mahesh Goel—critical revision of manuscript; Shailesh V. Shrikhande—study conception and design, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- 5.Gurusamy KS, Kumar S, Davidson BR et al (2014) Resection versus other treatments for locally advanced pancreatic cancer. Cochrane Database Syst Rev 2:CD010244Google Scholar
- 7.Temple SJ, Kim PTW, Serrano PE, Kagedan D, Cleary SP, Moulton CA, McGilvray ID, Gallinger S, Greig PD, Wei AC (2014) Combined pancreaticoduodenectomy and colon resection for locally advanced peri-ampullary tumours: analysis of peri-operative morbidity and mortality. HPB 16(9):797–800. https://doi.org/10.1111/hpb.12263 CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Hartwig W, Vollmer CM, Fingerhut A, Yeo CJ, Neoptolemos JP, Adham M, Andrén-Sandberg A, Asbun HJ, Bassi C, Bockhorn M, Charnley R, Conlon KC, Dervenis C, Fernandez-Cruz L, Friess H, Gouma DJ, Imrie CW, Lillemoe KD, Milićević MN, Montorsi M, Shrikhande SV, Vashist YK, Izbicki JR, Büchler MW, International Study Group on Pancreatic Surgery (2014) Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 156(1):1–14. https://doi.org/10.1016/j.surg.2014.02.009 CrossRefPubMedGoogle Scholar
- 12.World Medical Association Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects. http://www.wma.net/en/30publications/10policies/b3/. Accessed November 13, 2016
- 14.Shrikhande SV, Barreto SG, Bodhankar YD, Suradkar K, Shetty G, Hawaldar R, Goel M, Shukla PJ (2011) Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes. Langenbeck's Arch Surg 396(8):1205–1212. https://doi.org/10.1007/s00423-011-0824-5 CrossRefGoogle Scholar
- 16.Bockhorn M, Uzunoglu FG, Adham M, Imrie C, Milicevic M, Sandberg AA, Asbun HJ, Bassi C, Büchler M, Charnley RM, Conlon K, Cruz LF, Dervenis C, Fingerhutt A, Friess H, Gouma DJ, Hartwig W, Lillemoe KD, Montorsi M, Neoptolemos JP, Shrikhande SV, Takaori K, Traverso W, Vashist YK, Vollmer C, Yeo CJ, Izbicki JR, International Study Group of Pancreatic Surgery (2014) Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 155(6):977–988. https://doi.org/10.1016/j.surg.2014.02.001 CrossRefPubMedGoogle Scholar
- 18.Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142(1):20–25. https://doi.org/10.1016/j.surg.2007.02.001 CrossRefPubMedGoogle Scholar
- 20.Dindo D, Clavien PA (2004) Classification of surgical complications—a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Campbell F, Foulis AK, Verbeke CS (2010) Dataset for the histopathological reporting of carcinomas of the pancreas, ampulla of Vater and common bile duct. Royal college of Pathologists (May 2010). Available from https://www.rcpath.org/resourceLibrary/g091-draftpancreasdataset-nov16.html
- 29.Bhayani NH, Enomoto LM, James BC, Ortenzi G, Kaifi JT, Kimchi ET, Staveley-O'Carroll KF, Gusani NJ (2014) Multivisceral and extended resections during pancreatoduodenectomy increases morbidity and mortality. Surgery 155(3):567–574. https://doi.org/10.1016/j.surg.2013.12.020 CrossRefPubMedGoogle Scholar
- 34.Kleef J, Diener MK, Z’graggen K et al (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245(4):573–582. https://doi.org/10.1097/01.sla.0000251438.43135.fb CrossRefGoogle Scholar
- 40.Konstantinidis IT, Warshaw AL, Allen JN, Blaszkowsky LS, Castillo CF, Deshpande V, Hong TS, Kwak EL, Lauwers GY, Ryan DP, Wargo JA, Lillemoe KD, Ferrone CR (2013) Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a “true” R0 resection? Ann Surg 257(4):731–736. https://doi.org/10.1097/SLA.0b013e318263da2f CrossRefPubMedGoogle Scholar
- 41.Neoptolemos JP, Stocken DD, Dunn JA, Almond J, Beger HG, Pederzoli P, Bassi C, Dervenis C, Fernandez-Cruz L, Lacaine F, Buckels J, Deakin M, Adab FA, Sutton R, Imrie C, Ihse I, Tihanyi T, Olah A, Pedrazzoli S, Spooner D, Kerr DJ, Friess H, Büchler MW, European Study Group for Pancreatic Cancer (2001) Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg 234(6):758–768. https://doi.org/10.1097/00000658-200112000-00007 CrossRefPubMedPubMedCentralGoogle Scholar
- 42.Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB (2004) Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg 8(8):935–949. https://doi.org/10.1016/j.gassur.2004.09.046 CrossRefPubMedGoogle Scholar
- 43.Neoptolemos JP, Stocken DD, Bassi C, Ghaneh P, Cunningham D, Goldstein D, Padbury R, Moore MJ, Gallinger S, Mariette C, Wente MN, Izbicki JR, Friess H, Lerch MM, Dervenis C, Oláh A, Butturini G, Doi R, Lind PA, Smith D, Valle JW, Palmer DH, Buckels JA, Thompson J, McKay CJ, Rawcliffe CL, Büchler MW, European Study Group for Pancreatic Cancer (2010) Adjuvant chemotherapy with fluorouracil plus folinic acid vs. gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304(10):1073–1081. https://doi.org/10.1001/jama.2010.1275 CrossRefPubMedGoogle Scholar