Top

Langenbeck's Archives of Surgery

Published in:

01-03-2018 | ORIGINAL ARTICLE

Extended pancreatectomy as defined by the ISGPS: useful in selected cases of pancreatic cancer but invaluable in other complex pancreatic tumors

Authors: Abhishek Mitra, Esha Pai, Rohit Dusane, Priya Ranganathan, Ashwin DeSouza, Mahesh Goel, Shailesh V. Shrikhande

Published in: Langenbeck's Archives of Surgery | Issue 2/2018

Abstract

Purpose

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.

Methods

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.

Results

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).

Conclusion

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.

McDermott WV (1952) A one-stage pancreatoduodenectomy with resection of the portal vein for carcinoma of the pancreas. Ann Surg 136(6):1012–1018. https://doi.org/10.1097/00000658-195212000-00015 CrossRefPubMedPubMedCentral

Fortner JG (1984) Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Ann Surg 199(4):418–425. https://doi.org/10.1097/00000658-198404000-00008 CrossRefPubMedPubMedCentral

Baxter NN, Whitson BA, Tuttle TM (2007) Trends in the treatment and outcome of pancreatic cancer in the United States. Ann Surg Oncol 14(4):1320–1326. https://doi.org/10.1245/s10434-006-9249-8 CrossRefPubMed

Gillen S, Schuster T, Meyer Zum BC et al (2010) Pre-operative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med 7:e1000267CrossRefPubMedPubMedCentral

Gurusamy KS, Kumar S, Davidson BR et al (2014) Resection versus other treatments for locally advanced pancreatic cancer. Cochrane Database Syst Rev 2:CD010244

Ravikumar R, Sabin C, Hilal MA et al (2014) Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study. J Am Coll Surg 218:401–411CrossRefPubMed

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 CrossRefPubMedPubMedCentral

Dar FS, Bhatti AB, Dogar AW (2015) Is pancreaticoduodenectomy with vascular resection a safe procedure in developing country? Early outcomes and review of national literature. Int J Surg 21:8–13. https://doi.org/10.1016/j.ijsu.2015.06.073 CrossRefPubMed

Kulemann B, Hoeppner J, Wittel U (2015) Perioperative and long-term outcome after standard pancreaticoduodenectomy, additional portal vein and multivisceral resection for pancreatic head cancer. J Gastointest Surg 19(3):438–444. https://doi.org/10.1007/s11605-014-2725-8 CrossRef

10.

Shrikhande SV, Barreto SG (2010) Extended pancreatic resections and lymphadenectomy: an appraisal of the current evidence. World J Gatrointest Surg 2(1):39–46. https://doi.org/10.4240/wjgs.v2.i2.39 CrossRef

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 CrossRefPubMed

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

13.

Jagannath P, Dhir V, Shrikhande S et al (2005) Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg 92:356–361CrossRefPubMed

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 CrossRef

15.

Shrikhande SV, Barreto G, Shukla PJ (2008) Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy. Langenbeck's Arch Surg 393:87–91CrossRef

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 CrossRefPubMed

17.

Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 138:8–13CrossRefPubMed

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 CrossRefPubMed

19.

Wente MN, Bassi C, Dervenis C et al (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768CrossRefPubMed

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 CrossRefPubMedPubMedCentral

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

22.

Shoup M, Conlon KC, Klimstra D, Brennan MF (2003) Is extended resection for adenocarcinoma of the body or tail of the pancreas justified? J Gastrointest Surg 7(8):946–952. https://doi.org/10.1016/j.gassur.2003.08.004 CrossRefPubMed

23.

Hartwig W, Hackert T, Hinz U et al (2009) Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg 250:81–87CrossRefPubMed

24.

Hartwig W, Gluth A, Hinz U et al (2016) Outcomes after extended pancreatectomy in patients with borderline resectable and locally advanced pancreatic cancer. Br J Surg 103:1683–1694CrossRefPubMed

25.

Burdelski CM, Reeh M, Bogoevski D et al (2011) Multivisceral resections in pancreatic cancer: identification of risk factors. World J Surg 35:2756–2763CrossRefPubMed

26.

Jeong J, Choi DW, Choi SH, Heo JS, Jang KT (2015) Long-term outcome of portomesenteric vein invasion and prognostic factors in pancreas head adenocarcinoma. ANZ J Surg 85(4):264–269. https://doi.org/10.1111/ans.12502 CrossRefPubMed

27.

Malleo G, Maggino L, Marchegiani G et al (2017) Pancreatectomy with venous resection for pT3 head adenocarcinoma: perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration. Pancreatology 17:847–857CrossRefPubMed

28.

Banz VM, Croagh D, Coldham C et al (2012) Factors influencing outcome in patients undergoing portal vein resection for adenocarcinoma of the pancreas. Eur J Surg Oncol 38:72–79CrossRefPubMed

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 CrossRefPubMed

30.

Nikfarjam M, Sehmbey M, Kimchi ET et al (2009) Additional organ resection combined with pancreaticoduodenectomy does not increase postoperative morbidity and mortality. J Gastrointest Surg 13:915–921CrossRefPubMed

31.

Seeliger H, Christians S, Angele MK et al (2010) Risk factors for surgical complications in distal pancreatectomy. Am J Surg 200:311–317CrossRefPubMed

32.

Klempnauer J, Ridder GJ, Bektas H, Pichlmayr R (1996) Extended resections of ductal pancreatic cancer-impact on operative risk and prognosis. Oncology 53(1):47–53. https://doi.org/10.1159/000227534 CrossRefPubMed

33.

Roch AM, Singh H, Turner AP et al (2015) Extended distal pancreatectomy for pancreatic adenocarcinoma with splenic vein thrombosis and/or adjacent organ invasion. Am J Surg 209:564–569CrossRefPubMed

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 CrossRef

35.

Sasson AR, Hoffman JP, Ross EA et al (2002) En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg 6(2):147–157. https://doi.org/10.1016/S1091-255X(01)00063-4 CrossRefPubMed

36.

De Reuver PR, Mittal A, Neale M et al (2015) Extended pancreatoduodenectomy as defined by the International Study Group for Pancreatic Surgery is associated with worse survival but not with increased morbidity. Surgery 158:183–190CrossRefPubMed

37.

Schafer M, Mullhaupt B, Clavien PA (2002) Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 236:137–148CrossRefPubMedPubMedCentral

38.

Shibata C, Kobari M, Tsuchiya T et al (2001) Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas. World J Surg 25:1002–1005CrossRefPubMed

39.

Yoshimi F, Asato Y, Tanaka R et al (2003) Reconstruction of the portal vein and the splenic vein in pancreaticoduodenectomy for pancreatic cancer. Hepato-Gastroenterology 50:856–860PubMed

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 CrossRefPubMed

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 CrossRefPubMedPubMedCentral

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 CrossRefPubMed

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 CrossRefPubMed

44.

Shrikhande SV, Barreto SG, Somashekhar BA et al (2013) Evolution of pancreatoduodenectomy in a tertiary cancer centre in India: improved results from service reconfiguration. Pancreatology 13(1):63–71. https://doi.org/10.1016/j.pan.2012.11.302 CrossRefPubMed

45.

Bockhorn M, Burdelski C, Bogoevski D et al (2011) Arterial en bloc resection for pancreatic carcinoma. Br J Surg 98:86–92CrossRefPubMed

46.

Nentwich MF, Konig A, Izbicki JR (2014) Limits of surgery for pancreatic cancer. Rozhl Chir 93:445–449PubMed

47.

Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J (2011) Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 254(6):882–893. https://doi.org/10.1097/SLA.0b013e31823ac299 CrossRefPubMed

Title: Extended pancreatectomy as defined by the ISGPS: useful in selected cases of pancreatic cancer but invaluable in other complex pancreatic tumors
Authors: Abhishek Mitra
Esha Pai
Rohit Dusane
Priya Ranganathan
Ashwin DeSouza
Mahesh Goel
Shailesh V. Shrikhande
Publication date: 01-03-2018
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 2/2018
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-018-1653-6

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Extended pancreatectomy as defined by the ISGPS: useful in selected cases of pancreatic cancer but invaluable in other complex pancreatic tumors

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 2/2018

Conception of the Lübeck Toolbox curriculum for basic minimally invasive surgery skills

Utility of C-reactive protein as predictive biomarker of anastomotic leak after minimally invasive esophagectomy

Outcome of concomitant resection of the replaced right hepatic artery in pancreaticoduodenectomy without reconstruction

Radiofrequency ablation for locally advanced pancreatic cancer: SMAD4 analysis segregates a responsive subgroup of patients

Implication of visceral obesity in patients with esophageal squamous cell carcinoma

Standardizing procedures improves and homogenizes short-term outcomes after minimally invasive esophagectomy