Intraoperative Positive Pancreatic Parenchymal Resection Margin: Is It a True Indication of Completion Total Pancreatectomy after Partial Pancreatectomy for Pancreatic Ductal Adenocarcinoma?

Abstract

Background: Total pancreatectomy (TP) can be performed in cases with positive resection margin after partial pancreatectomy for pancreatic cancer. However, despite complete removal of the residual pancreatic parenchyme, it is questionable whether an actual R0 resection and favorable survival can be achieved. This study aimed to identify the R0 resection rate and postoperative outcomes, including survival, following completion TP (cTP) performed due to intraoperative positive margin. Methods: From 1995 to 2015, 1096 patients with pancreatic ductal adenocarcinoma underwent elective pancreatectomy at the Samsung Medical Center. Among these, 25 patients underwent cTP, which was converted during partial pancreatectomy because of a positive resection margin. To compare survival after R0 resection between the cTP R0 and pancreaticoduodenectomy (PD) R0 cases, propensity score matching was conducted to balance the baseline characteristics. Results: The R0 rate of cTP performed due to intraoperative positive margin was 84% (21/25). The overall 5-year survival rate (5YSR) in the 25 cTP cases was 8%. There was no difference in the 5YSR between the cTP R0 and cTP R1 groups (9.5% versus 0.0%, p = 0.963). However, the 5YSR of the cTP R0 group was significantly lower than that of the PD R0 group (9.5% versus 20.0%, p = 0.022). There was no distinct difference in postoperative complications between the cTP R0 versus cTP R1 and cTP R0 versus PD R0 groups. Conclusions: In cases with intraoperative positive pancreatic parenchymal resection margin, survival after cTP was not favorable. Careful patient selection is needed to perform cTP in such cases.

Comparison of clinical outcomes and prognosis between total pancreatectomy and pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a systematic review and meta‐analysis

“…The flowchart of the literature search process is shown in Figure 1. A total of 4431 articles were retrieved, and after rigorous screening, six studies [20][21][22][27][28][29] were included in the systematic review, with a total of 8396 patients, including 1696 patients in the TP group and 6700 patients in the PD group. One study was from Japan, 21 one from Korea, 28 two from the USA, 20,27 and two from China.…”

“…A total of 4431 articles were retrieved, and after rigorous screening, six studies [20][21][22][27][28][29] were included in the systematic review, with a total of 8396 patients, including 1696 patients in the TP group and 6700 patients in the PD group. One study was from Japan, 21 one from Korea, 28 two from the USA, 20,27 and two from China. 22,29 All six studies were retrospective, with three studies 21,22,29 using matched-pair analysis, and four studies [20][21][22]29 using Cox regression-based multivariate analyses for prognostic analysis.…”

“…Baseline data for all study patients are detailed in Table 1. According to the NOS, three studies scored 9 points, 21,22,28 two studies scored 8 points, 20,29 and one study scored 7 points, 27 all of which were high-quality literatures.…”

“…There is considerable controversy over the comparison of long‐term survival after two different surgeries for PDAC. One study 20 suggests that 5‐OS of the TP is significantly higher than that of PD, while another study 28 suggests the opposite. Reddy et al 19 found that 1‐OS of the TP was significantly lower than that of the PD, but that 3‐OS and 5‐OS were similar to those of the PD.…”

“…Four studies [20][21][22]29 provided HR based on multivariate analysis, and two studies 27,28 obtained HR by extracting survival curve values. The combined results of the six studies showed high heterogeneity (I 2 = 69%, P < 0.01), and random effects model analysis suggested no statistically significant difference in OS between the two groups of patients (HR = 1.08, 95% CI: 0.91-1.27; P = 0.38).…”