Standardized radical resection for pancreatic head cancer does improve local control

Background:

Survival after surgery for pancreatic ductal adenocarcinoma (PDAC) is poor despite improvements in surgical care and chemotherapeutic regimes. R0 resections and adjuvant chemotherapy are the only chances for cure. The degree of radical surgery has been a questionable prognostic parameter, reasoned by the difficulty for sub-stratification. However, after the LEEDS protocol implementation the rate of ''true'' R0 resections have dropped drastically. In our institution a standardized radical lymphadenectomy of the superior mesenteric artery, common hepatic artery, hepatoduodenal ligament and interoaortocaval lymphnodes (LN) with dissection of the aortic and para-aortic nerve plexus and removement of the retro pancreatic lamina, has been standardized during pancreatoduodenectomies (PD). The aim of this study is to propose our surgical strategy and to analyze the influence of CRM with the R0 rate, OS and DFS, and sight and rate of metachronous disease.

Method:

Clinicopathological data from 309 patients who were undergoing PD between 2003 and 2019 were analyzed. Histopathologic reports were re-assessed to the 8^th UICC edition. From 2003 – 2015 no pathological pancreas protocol was used. The CRM was implemented 2015. Margin clearance was correlated between subgroups. Follow up results were protocolled and OS and DFS was determined for all patients by Kaplan-Meier and Cox regression.

Results:

Of the 309 patients, 85.7% underwent partial PD; while 4.5% received total PDs. 29 patients, which received oncologic pancreatic tail resections, were exluded from this study. 80.5% were staged N1, while 15% presented with synchronous distant metastasis. The rate of R0 resection remained 70%, irrespective of pathological analysis. In multivariat analysis, only R0 resection was an independent prognostic marker. Hospital stay and morbidity rates are comparable to the known literature. (average hospital stay 27 days, morbidity 11%). On follow-Up analysis local recurrence was diagnosed in only 14% of all patients.

Conclusion:

Due to ''the duesseldorf protocol'' no effect on R0 rate was discovered despite CRM implementation. Local control is established, as a minor amount of patients presented with local recurrence in follow up examinations.