Elsevier

Surgery

Volume 162, Issue 4, October 2017, Pages 802-811
Surgery

Pancreas
Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: Long-term oncologic outcomes after standard resection

https://doi.org/10.1016/j.surg.2017.06.009Get rights and content

Background

Surgical resection is the only curative option in patients with pancreatic ductal adenocarcinoma. Little is known about the oncologic outcomes of laparoscopic distal pancreatectomy. This bi-institutional study aimed to examine the long-term oncologic results of standard laparoscopic distal pancreatectomy in a large cohort of patients with pancreatic ductal adenocarcinoma.

Methods

From January 2002 to March 2016, 207 patients underwent standard laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma at Oslo University Hospital-Rikshospitalet (Oslo, Norway) and Asan Medical Centre (Seoul, Republic of Korea). After the exclusion criteria were applied (distant metastases at operation, conversion to an open operation, loss to follow-up), 186 patients were eligible for the analysis. Perioperative and oncologic variables were analyzed for association with recurrence and survival.

Results

Median overall and recurrence-free survivals were 32 and 16 months, while 5-year overall and recurrence-free survival rates were estimated to be 38.2% and 35.9%, respectively. Ninety-six (52%) patients developed recurrence: 56 (30%) extrapancreatic, 27 (15%) locoregional, and 13 (7%) combined locoregional and extrapancreatic. Thirty-seven (19.9%) patients had early recurrence (within 6 months of operation). In the multivariable analysis, tumor size >3 cm and no adjuvant chemotherapy were associated with early recurrence (P = .017 and P = .015, respectively). The Cox regression model showed that tumor size >3 cm and lymphovascular invasion were independent predictors of decreased recurrence-free and overall survival.

Conclusion

Standard laparoscopic distal pancreatectomy is associated with satisfactory long-term oncologic outcomes in patients with pancreatic ductal adenocarcinoma. Several risk factors, such as tumor size >3 cm, no adjuvant chemotherapy, and lymphovascular invasion, are linked to poor prognosis after standard laparoscopic distal pancreatectomy.

Section snippets

Design and patients

The study population comprised consecutive patients with PDAC who underwent LDP at the Oslo University Hospital-Rikshospitalet ([OUH] Oslo, Norway) and the Asan Medical Centre ([AMC] Seoul, South Korea) from January 2002 to March 2016. Patients with intraductal papillary mucinous and adenosquamous carcinoma were excluded due to different tumor characteristics and prognosis.14, 15 Neoadjuvant treatment was not a part of the standard management scheme in patients with resectable PDAC, but

Operative and short-term oncologic outcomes

Of the 262 patients with PDAC who underwent LDP between January 2002 and March 2016, 207 (79%) underwent SLDP, while 47 (17.9%) underwent extended LDP due to tumor invasion to adjacent organ(s). Eight (3.1%) patients underwent CLDP for distant metastases of PDAC detected at the time of operation.

Demographics, clinical characteristics, and perioperative outcomes of patients undergoing SLDP are presented in Table I. One hundred forty-four patients were operated at AMC, and 63 at OUH. Six (2.9%)

Discussion

This study suggests that SLDP is associated with acceptable long-term oncologic outcomes in patients with PDAC. Nevertheless, more than half of patients were diagnosed with tumor recurrence on a median follow-up period of 18 months. Liver metastases and locoregional recurrence were the most common of types of tumor relapse, which is consistent with previous reports22, 23; however, these studies focused mainly on pancreatoduodenectomy, whereas similar data after LDP are limited to small case

References (56)

  • H. Park et al.

    Survival effect of tumor size and extrapancreatic extension in surgically resected pancreatic cancer: proposal for improved T classification

    Human Pathol

    (2014)
  • D. Petermann et al.

    Is tumour size an underestimated feature in the current TNM system for malignancies of the pancreatic head?

    HPB (Oxford)

    (2013)
  • I. Matsumoto et al.

    Proposed preoperative risk factors for early recurrence in patients with resectable pancreatic ductal adenocarcinoma after surgical resection: a multi-center retrospective study

    Pancreatology

    (2015)
  • J.W. Chen et al.

    Predicting patient survival after pancreaticoduodenectomy for malignancy: histopathological criteria based on perineural infiltration and lymphovascular invasion

    HPB (Oxford)

    (2010)
  • T. de Rooij et al.

    A nationwide comparison of laparoscopic and open distal pancreatectomy for benign and malignant disease

    J Am Coll Surg

    (2015)
  • Y. Murakami et al.

    Number of metastatic lymph nodes, but not lymph node ratio, is an independent prognostic factor after resection of pancreatic carcinoma

    J Am Coll Surg

    (2010)
  • H. Riediger et al.

    The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer

    J Gastrointest Surg

    (2009)
  • T.A. Sohn et al.

    Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators

    J Gastrointest Surg

    (2000)
  • T. Sugiura et al.

    Serum CA19-9 is a significant predictor among preoperative parameters for early recurrence after resection of pancreatic adenocarcinoma

    J Gastrointest Surg

    (2012)
  • T.H. Kim et al.

    CA 19-9 level as indicator of early distant metastasis and therapeutic selection in resected pancreatic cancer

    Int J Radiat Oncol Biol Phys

    (2011)
  • M.J. Morak et al.

    Staging for locally advanced pancreatic cancer

    Eur J Surg Oncol

    (2009)
  • K.K. Christians et al.

    Survival of patients with resectable pancreatic cancer who received neoadjuvant therapy

    Surgery

    (2016)
  • A.B. Cooper et al.

    Role of neoadjuvant therapy in the multimodality treatment of older patients with pancreatic cancer

    J Am Coll Surg

    (2014)
  • S.W. de Geus et al.

    Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: a Markov decision analysis

    Eur J Surg Oncol

    (2016)
  • A.E. Becker et al.

    Pancreatic ductal adenocarcinoma: risk factors, screening, and early detection

    World J Gastroenterol

    (2014)
  • J. Huang et al.

    Variant profiling of candidate genes in pancreatic ductal adenocarcinoma

    Clin Chem

    (2015)
  • L. Sulpice et al.

    Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: time for a randomized controlled trial? Results of an all-inclusive national observational study

    Ann Surg

    (2015)
  • M. Abu Hilal et al.

    Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results

    Surg Endosc

    (2016)
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