Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR): An International Multicenter Analysis

Abstract

Background Distal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes. Methods This multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000–2016) and three very-high-volume international centers in the United States and Japan (model validation 2004–2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival. Results For 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2–11%) at 5 high-volume (≥ 1 DP-CAR/year) and 18% (95 CI, 9–30%) at 18 low-volume DP-CAR centers ( P = 0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P = 0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19 months (95 CI, 15–25 months). Conclusions When performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor. Electronic supplementary material The online version of this article (10.1245/s10434-018-07101-0) contains supplementary material, which is available to authorized users.

Factors predicting survival in patients with locally advanced pancreatic cancer undergoing pancreatectomy with arterial resection

“…For many years, the high morbidity and mortality [7,9,10] and the uncertain survival advantage of P-Ar [6,9] have discouraged surgeons from undertaking such major procedures. More recently, several groups have reported encouraging results [8,9,12,[34][35][36][37], the AJCC has removed the status "unresectable" from the definition of T4 [38], and NCCN guidelines included resection among the treatment options for LAPC following neoadjuvant treatments [39]. The growing interest in P-Ar is also shown by the description of newer approaches to deal with LAPC, such as arterial divestment following primary chemotherapy [40][41][42].…”

Local radicality and survival outcome of pancreatic cancer surgery

“…Feasibility and acceptable safety with mortality rates of 3%‐8% after DP‐CAR were demonstrated in several single‐center observational studies . In a recent retrospective international multicenter study including 191 patients undergoing DP‐CAR, the 90‐day mortality rate was 5.5% at five high‐volume but as high as 18% at 18 low‐volume DP‐CAR centers, demonstrating the importance of experience with this rare and complex procedure . In a multicenter study performed in 20 European centers in 12 countries, the median survival of 68 patients undergoing DP‐CAR was 18 months .…”

Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer?

“…Although improved resectability and the favorable long-term outcome can be expected, relatively high rates of morbidity and mortality have been reported [12, 13]. According to a recent international multicenter analysis, the postoperative morbidity and mortality rates of DP-CAR are between 25.0% and 28.0% and 6.0% and 16.0%, respectively [14]. In this procedure, the CeA, CHA, and left gastric artery (LGA), which are major sources of arterial blood flow of the liver and stomach, are resected and are not reconstructed.…”