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A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy with Major Vascular Resection in Pancreatic Cancer

  • 2015 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Previous studies examining short- and long-term outcomes of pancreaticoduodenectomy with vascular resection for pancreatic adenocarcinoma have not graded perioperative complication severity. These studies may provide incomplete assessments of the efficacy of vascular resection. In the current study, we evaluated 36 patients who had pancreaticoduodenectomy with major vascular resection. These were matched 1:3 by tumor stage and age to patients who had pancreaticoduodenectomy without vascular resection. Charts were reviewed to identify all complications and 90-day readmissions. Complications were graded as either severe or minor adverse postoperative outcomes, taking into account the total length of stay. There were no statistical differences in patient demographics, comorbidities, or symptoms between the groups. Patients who had vascular resection had significantly increased rates of severe adverse postoperative outcomes, readmissions, lengths of hospital stay, as well as higher hospital costs. Hypoalbuminemia and major vascular resection were independent predictors of severe adverse postoperative outcomes. On multivariate Cox-regression survival analysis, patients who had vascular resection had decreased recurrence-free (12 vs. 17 months) and overall (17 vs. 29 months) survival. Major vascular resection was a predictor of mortality, may be an independent prognostic factor for survival, and may warrant incorporation into future staging systems.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Chicago, Chicago, IL, USA

    Olga Kantor

  2. Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL, 60201, USA

    Mark S. Talamonti, Susan J. Stocker, David J. Winchester, Richard A. Prinz & Marshall S. Baker

  3. Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA

    Chi-Hsiung Wang

  4. Department of Surgery, Northwestern University, Chicago, IL, USA

    David J. Bentrem

Authors
  1. Olga Kantor
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  2. Mark S. Talamonti
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  3. Susan J. Stocker
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  4. Chi-Hsiung Wang
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  8. Marshall S. Baker
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Corresponding author

Correspondence to Marshall S. Baker.

Additional information

Primary Discussant

Jennifer F. Tseng, M.D. MPH (Boston, MA)

Dr Kantor, Dr. Baker, congratulations on your talk on an important subject in pancreatic surgery. I have 2 questions.

1). 50 % of your 36 patients underwent primary transverse closure and 31 % underwent end-to-end anastomosis over the 7 years of the study. This 81 % rate of primary reconstruction without patch or graft is higher than that reported in many studies and may suggest intraoperative decision making rather than preoperative planning for venous resection necessitating reconstruction. Were these vascular reconstructions planned a priori based on imaging or intraoperative necessity due to unexpected tumor involvement and/or bleeding at the time of operation? This might influence the increased complications and worse outcomes from the VR group.

2). You had a 56 % rate of neoadjvuant therapy in the VR group versus 13 % in the matched control group. Was survival (time to recurrence) calculated from diagnosis, as would be appropriate in a study where some patients received neoadjuvant therapy, or from surgery, which would bias the survival against the VR group?

Thank you for the opportunity to review.

Closing Discussant

Dr. Kantor

Dr. Tseng, thank you for reviewing our manuscript and your thoughtful comments.

1). With regard to your first question, for this study we identified all patients that had vascular resections by a retrospective query of our institutional pancreatic database. We then reviewed operative notes and had additional separate discussion with the operating surgeons to clarify the indications/reasons for the vein resection. For our analysis, we excluded vein resections that were done for accidental vascular injuries as well as unplanned vascular resections. .

2). With regard to your second question, overall survival was calculated from time of surgery. We felt that either choice for the point of origin for the survival analysis (from date of surgery or date of diagnosis) would have the potential to introduce bias. We did have many patients that received neoadjuvant chemotherapy in our vascular resection group. All of these patients were selected retrospectively and thus were by nature patients who survived through neoadjuvant therapy to surgery. We felt that using the time of diagnosis would create bias in the sense that none of these patients would have had any possibility of mortality during the course of neoadjuvant chemotherapy. We also do not have data on how many patients would have dropped out (developed metastatic disease) during neoadjuvant treatment. For these reasons, in an analysis starting at time of diagnosis, patients in this cohort would have thus had a built in survival advantage. On the other hand, using date of surgery, “takes” time away from these individuals in the sense that it excludes the time in chemotherapy from the survival calculations. At our institution we typically give short courses of neoadjuvant therapy: approximately two months of treatment with a third month left for recovery prior to surgery. While using the starting point for the survival analysis as the date of surgery could certainly introduce a bias that would reflect negatively on the survival statistics of patients in the vascular resection cohort, the observed difference in overall survival between the groups was wide enough (9 months) that it would be expected to continue to be significant even if neoadjuvant treatment time was added back to all affected vascular resection patients. In the end, we felt the least problematic method was to use the date of surgery as the start point for our survival calculation.

Plenary Presentation at 2015 SSAT Annual Meeting on May 19, 2015 in Washington, DC

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Kantor, O., Talamonti, M.S., Stocker, S.J. et al. A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy with Major Vascular Resection in Pancreatic Cancer. J Gastrointest Surg 20, 284–292 (2016). https://doi.org/10.1007/s11605-015-2957-2

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  • DOI: https://doi.org/10.1007/s11605-015-2957-2

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