Arterial Resection in Pancreatic Cancer Surgery

Abstract

Objective:To investigate the perioperative and oncologic long-term outcomes of patients with LAPC after surgical resection at a high-volume center for pancreatic surgery.Background:The role of surgery in LAPC with arterial involvement is controversial.Methods:We analyzed 385 consecutive patients undergoing PAR (n = 195) or PAD (n = 190) of the encased artery for LAPC between January 1, 2003 and April 30, 2019.Results:There were 183 total pancreatectomies, 113 partial pancreatoduodenectomies, 79 distal pancreatectomies, and 10 resections for tumor recurrences, including 121 multivisceral resections and 171 venous resections. Forty-three patients (11.4%) had resectable oligometastatic disease. All of the 190 patients undergoing PAD (100%) and 95 of the 195 patients undergoing PAR (48.7%) received neoadjuvant chemotherapy. The R0 (circumferential resection margin negative) resection rate was 28%. The median hospital stay was 15 days (range: 3–236). The median survival after surgery for LAPC was 20.1 months and the overall 5-year survival rate 12.5%. In-hospital mortality was 8.8% for the entire patient cohort (n = 385). With increasing case load and growing expertise, there was a significant reduction of in-hospital mortality to 4.8% (n = 186) after 2013 (P = 0.005). The learning curve of experienced pancreatic surgeons for PAR was 15 such procedures.Conclusion:Our data demonstrate that an arterial surgical approach is effective in LAPC with promising long-term survival. PAD after neoadjuvant treatment is safe. PAR is a technically demanding procedure and requires a high level of expertise.

Selecting surgical candidates with locally advanced pancreatic cancer: a review for modern pancreatology

“…The large majority of studies on LAPC involve a small and very well selected group of patients, therefore there is a presence of selection bias. In a recent and large series published by one of the most experienced groups in the treatment of LAPC, the overall mortality rate was 8.8%, with a significant decrease to 4.8% in recent years (25).…”

“…Several attempts have been made to stratify patient prognosis based on the overall characteristics of a tumor instead of purely on anatomic features (22)(23)(24). With the improvement of oncologic therapy, studies have shown that arterial resections in well-selected cases can achieve similar longterm overall survival in experienced centers (9,25,26). The shift in this concept is critical as several reports have indicated that surgical resection after NAT for LAPC, even for metastatic PC, can give a significant increase in survival rate and even a chance for cure (16,18,19).…”

Surgical Treatment of Pancreatic Ductal Adenocarcinoma

“…Another recent study covering nearly 40 years of experience showed that any type of arterial resection was performed at a frequency of 6% (44/730 patients) and confirmed the safety and efficacy of these operations for patients with locally advanced pancreatic cancer, additionally suggesting preoperative therapy with artery resection as a useful concept for locally advanced pancreatic cancer [ 76 ]. An important aspect in selecting patients properly and gaining sufficient surgical experience to safely perform such procedure which has recently been shown in two large series that demonstrated the impact of the surgical learning curve in two single center collectives of 111 and 195 patients, respectively [ 77 , 78 ].…”

Surgery for pancreatic cancer: recent progress and future directions

“…Arterial resection with pancreatectomy remains controversial both because of increased perioperative morbidity and mortality but also less clear oncologic benefit. Nevertheless, pancreatectomy with arterial resection continues to be performed at experienced centers with acceptable outcomes in order to extend the benefits of surgery to more patients (7).…”