Background: Positive margins in pancreatoduodenectomy (PD) for pancreatic cancer, specifically the superior mesenteric artery (SMA) margin, are associated with worse outcomes. Local therapies targeting these margins could impact on recurrence. This study analysed recurrence-patterns to identify whether strategies to control local disease could have a meaningful impact. Methods: (I) Systematic review to define recurrence patterns and resection margin status. (II) Additional retrospective study of PD performed at our centre.Results: In the systematic review, 23/617 evaluated studies were included (n = 3815). Local recurrence was observed in 7-69%. SMA margin (6 studies) was positive in 15-35%. In the retrospective study (n = 204), local recurrence was more frequently observed with a positive SMA margin (66 vs.45%; p = 0.005). Furthermore, in a multivariate cox-proportional hazard model, only a positive SMA margin was associated with disease recurrence (HR 1.615; 95%CI 1.127-2.315; p = 0.009). Interestingly, median overall survival was 20 months and similar for patients who developed local only, metastases only or simultaneous recurrence (p = 0.124). Conclusion:Local recurrence of pancreatic cancer is common and associated with similar mortality rates as those who present with simultaneous or metastatic recurrence. Involvement of the SMA margin is an independent predictor for disease progression and should be the target of future adjuvant local therapies.
invagination PJ vs. duct to mucosa PJ (OR 0.60; 95%CI: 0.40-0.90; p=0.01); pancreaticogastrostomy (PG) vs. PJ (OR 0.69; 95%CI: 0.49-0.99; p=0.04) and omission of intraabdominal drains in patients with low risk PJ anastomoses (OR 0.52; 95%CI: 0.34-0.81; p< 0.005). Two interventions with data available from only one RCT were shown to reduce POPF: end to side vs. classic pancreaticojejunostomy (PJ) (OR 0.25; 95%CI 0.07-0.96; p=0.041) and closed suction drainage of pancreatic duct (OR 0.44; 95%CI: 0.2-0.99; p=0.045). One intervention, acute normovolaemic haemodilution, increased POPF rate in one RCT (OR 3.29 95%CI:1.11-9.77; p=0.045). Conclusions: Current evidence for perioperative interventions to reduce POPF after PD is heterogenous and frequently from underpowered RCTs. To further clinical knowledge in this complex field future RCTs should be better powered and flexible enough to involve evaluation of the promising novel strategies identified in this review.
Background: Outcomes after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remain poor. Resection margins are often involved with tumour, which is associated with local recurrence. Currently, adjuvant systemic therapy is the only available treatment to reduce recurrent disease. Local adjuvant therapies may impact upon outcome after PD. The aim of this study was therefore to analyse the patterns of recurrence after PD for PDAC to identify whether the strategies to control local disease may have a meaningful impact. Methods: In this retrospective study (2007e2015) consecutive patients undergoing PD with PDAC were identified. Potential benefit was assessed from two perspectives: recurrence pattern (only local recurrence or late recurrence (>18 months)) and positive resection margins (presence of tumour at SMA margin). Results: 204 patients survived >90 days with sufficient follow up data. Median survival was 20 months and 163 patients (79%) had recurrence. Local recurrence was observed in 109 (53%) patients, and more frequent, but by no means confined to those patients with positive resection margins (62% vs. 45%; p=0.012). Table 1 further demonstrates patterns of recurrent disease by anatomical location and the timing of disease recurrence. The SMA margin was most commonly affected (36%) and nearly one third of all patients developed local only recurrence (27%). Conclusion: A large proportion of patients develop local recurrence after PD. Novel strategies to improve outcomes after surgery for PDAC are needed. This study suggests that targeting local may benefit a significant proportion of patients.
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