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a Graded Evaluation of Outcomes Following Pancreaticoduodenectomy With Major Vascular Resection in Pancreatic Cancer: Major Vascular Resection Is Associated With Severe Adverse Postoperative Outcome and Early Recurrence
OLGA Kantor*1, Mark Talamonti2, Susan J. Stocker2, Chi Wang3, David J. Winchester2, Richard a. Prinz2, Marshall Baker2
1Department of Surgery, University of Chicago Medicine, Chicago, IL; 2Department of Surgery, NorthShore University HealthSystem, Chicago, IL; 3Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL
Introduction:
Recent multi-center retrospective studies in pancreatic cancer (PDAC) report disease specific survival following pancreaticoduodenectomy with major vascular resection (PDVR) to be superior to that for palliative bypass and comparable to that for pancreaticoduodenectomy not requiring vascular resection (PD). These studies have not graded perioperative complications and provide incomplete assessments of the value of PDVR.
Methods:
We queried our institutional database identifying 24 patients undergoing PDVR for PDAC between 2007 and 2013. Propensity score matching was used to match this cohort (3:1) by age, gender and tumor stage to 72 patients undergoing PD in the same period. Charts were reviewed for all complications and 90-day readmissions. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse postoperative outcomes (SAPO). Grade I, II and IIIa complications requiring more than one interventional procedure or overall lengths of stay (LOS) including readmissions >3 standard deviations beyond the mean for patients without complications were also classified as SAPO. All others were considered minor adverse outcomes.
Results:
There were no statistical differences in demographics, comorbid disease, preoperative albumin, rates of R0 resection, use of neoadjuvant chemotherapy (NAC), or incidence of recurrent PDAC between groups. Patients undergoing PDVR were more likely to have had antrectomy (75.0 vs 36.1%, p=0.001), had higher intraoperative blood loss (1.3±1.1 vs 0.45±0.3L; p<0.001) and longer operative times (7.5±1.6 vs 5.8±1.1 hrs; p<0.001) than those undergoing PD. PDVR patients were more likely to require readmission (41.7 vs 15.3%, p=0.01), demonstrated longer LOS (22.2±15.8 vs 13.5±8.8 days, p=0.008), were more likely to have a SAPO (66.7 vs 19.4%, p<0.001) and to miss adjuvant chemotherapy (33.3 vs 4.2%, p=0.001). Disease free and overall survival intervals were shorter in the PDVR group (9.2±8.1 vs 18.9±17.1 months and 12.3±10.7 vs 24.2±17.7months; p≤0.002). Multivariate logistic regression adjusted for age, comorbidities, hypoalbuminemia, NAC, tumor size and PDVR identified age ≥70 years (OR 3.62 [1.04,12.67]) and PDVR (OR 11.18 [2.98,41.89]) as independent predictors of SAPO. Cox-regression also adjusting for SAPO identified PDVR (HR 2.11 [1.12,3.98]) and tumor size ≥3cm (HR 2.37 [1.48,3.81]) as independent predictors of long term overall mortality.
Conclusions:
PDVR results in a higher severity complication profile than that seen for PD. Patients requiring PDVR for PDAC are less likely to receive adjuvant chemotherapy and demonstrate earlier disease recurrence than those undergoing PD. Well powered trials carefully evaluating perioperative complications and long term outcomes are required to determine the true value of PDVR for patients with resectable and borderline resectable PDAC.
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