Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma

Harish Lavu, Andres A. Mascaro, Dane R. Grenda, Patricia K. Sauter, Benjamin E. Leiby, Sean P. Croker, Agnes Witkiewicz, Adam C. Berger, Ernest L. Rosato, Eugene P. Kennedy, Charles J. Yeo

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

Background Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. Objective The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. Methods We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. Results We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. Conclusions Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

Original languageEnglish (US)
Pages (from-to)1937-1947
Number of pages11
JournalJournal of Gastrointestinal Surgery
Volume13
Issue number11
DOIs
StatePublished - 2009

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Pancreaticoduodenectomy
Adenocarcinoma
Gastric Bypass
Survival
Celiac Plexus
Neoadjuvant Therapy
Mortality
Age Distribution
Bile Ducts
Comorbidity
Pancreas
Neck

ASJC Scopus subject areas

  • Surgery
  • Gastroenterology
  • Medicine(all)

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Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma. / Lavu, Harish; Mascaro, Andres A.; Grenda, Dane R.; Sauter, Patricia K.; Leiby, Benjamin E.; Croker, Sean P.; Witkiewicz, Agnes; Berger, Adam C.; Rosato, Ernest L.; Kennedy, Eugene P.; Yeo, Charles J.

In: Journal of Gastrointestinal Surgery, Vol. 13, No. 11, 2009, p. 1937-1947.

Research output: Contribution to journalArticle

Lavu, H, Mascaro, AA, Grenda, DR, Sauter, PK, Leiby, BE, Croker, SP, Witkiewicz, A, Berger, AC, Rosato, EL, Kennedy, EP & Yeo, CJ 2009, 'Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma', Journal of Gastrointestinal Surgery, vol. 13, no. 11, pp. 1937-1947. https://doi.org/10.1007/s11605-009-1000-x
Lavu, Harish ; Mascaro, Andres A. ; Grenda, Dane R. ; Sauter, Patricia K. ; Leiby, Benjamin E. ; Croker, Sean P. ; Witkiewicz, Agnes ; Berger, Adam C. ; Rosato, Ernest L. ; Kennedy, Eugene P. ; Yeo, Charles J. / Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma. In: Journal of Gastrointestinal Surgery. 2009 ; Vol. 13, No. 11. pp. 1937-1947.
@article{4d5ae04a53454fed8e203f7a6bbf6aaf,
title = "Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma",
abstract = "Background Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. Objective The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. Methods We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. Results We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58{\%} underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38{\%} underwent GJ alone, and 4{\%} underwent HJ alone. Of these PB patients, 25{\%} had locally advanced disease and 75{\%} had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57{\%} retroperitoneal soft tissue, 19{\%} with more than one positive margin, 11{\%} pancreatic neck, and 8{\%} bile duct. The perioperative complication rates for the respective groups were R0 36{\%}, MP 49{\%}, PB 33{\%}, and PX 22{\%}. The 30-day perioperative mortality rate for the entire cohort was 2{\%}, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. Conclusions Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.",
author = "Harish Lavu and Mascaro, {Andres A.} and Grenda, {Dane R.} and Sauter, {Patricia K.} and Leiby, {Benjamin E.} and Croker, {Sean P.} and Agnes Witkiewicz and Berger, {Adam C.} and Rosato, {Ernest L.} and Kennedy, {Eugene P.} and Yeo, {Charles J.}",
year = "2009",
doi = "10.1007/s11605-009-1000-x",
language = "English (US)",
volume = "13",
pages = "1937--1947",
journal = "Journal of Gastrointestinal Surgery",
issn = "1091-255X",
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TY - JOUR

T1 - Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma

AU - Lavu, Harish

AU - Mascaro, Andres A.

AU - Grenda, Dane R.

AU - Sauter, Patricia K.

AU - Leiby, Benjamin E.

AU - Croker, Sean P.

AU - Witkiewicz, Agnes

AU - Berger, Adam C.

AU - Rosato, Ernest L.

AU - Kennedy, Eugene P.

AU - Yeo, Charles J.

PY - 2009

Y1 - 2009

N2 - Background Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. Objective The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. Methods We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. Results We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. Conclusions Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

AB - Background Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. Objective The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. Methods We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. Results We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. Conclusions Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

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