Francesca Aleotti, Giovanni Guarneri, Stefano Crippa, Domenico Tamburrino, Stefano Partelli, Gianpaolo Balzano, Claudio Doglioni, Corrado Rubini, Giuseppe Zamboni, Michele Pagnanelli, Alessandro Fogliati, Giulia Gasparini, Massimo Falconi
Background: During pancreatectomy for ductal adenocarcinoma (PDAC) an intra-operative frozen section analysis of the transection margin is usually performed to achieve an R0 resection. An extension of the resection is required for positive margins until a total pancreatectomy (TP). However, it is unclear whether an extended resection up to TP leads to a survival advantage. This study aims to evaluate disease-specific (DSS) and disease-free (DFS) survival in patients who underwent TP for PDAC compared to standard or extended pancreaticoduodenectomy (PD).
Methods: Patients with head PDAC were divided into three groups per type of resection: standard PD (SPD), extended PD (EPD) or TP because positive transection margin(s). Patients with intraductal papillary mucinous neoplasm (IPMN)-associated PDAC were excluded. Survival analysis as well as evaluation of pathological data and postop morbidity/mortality were performed.
Results: Between 2009 and 2016, 313 patients underwent SPD, 22 EPD group and in 36 TP was performed because of repeated positive margins. The three groups were homogenous for age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score and intra-operative variables. No differences were observed among the three groups regarding N+ rate, number of positive nodes and lymph node-ratio, perineural and microvascular invasion. In the TP group a statistically significant increase in peri-operative mortality [odds ratio (OR): 2.1, 95% CI: 0.03–0.50, P=0.04] was observed. Moreover, in TP group the rate of R1 resections was significantly higher than in SPD and EPD groups (χ2: 4.52, P=0.033). Compared to SPD and EPD patients, those who underwent TP had a significant decrease of DFS (median: 11 months in TP, 12 in EPD and 20 in SPD, P=0.002) and DSS (median: 16 months in TP, 17 in EPD and 27 in SPD, P=0.001).
Conclusions: In patients with head PDAC, TP performed to achieve a negative pancreatic resection margin is still associated with a significant rate of R1 resection (retroperitoneal margin), with higher postoperative mortality and worse both DFS and DSS, when compared to SPD or EPD. Therefore, in this setting, once after PD the transection margin is positive TP does not seem useful.
