Extended distal pancreatectomy in pancreatic cancer: is it justified? A systematic review of literature
Abstract
Background: Extended distal pancreatectomy (EDP) is being increasingly performed for pancreatic cancers with suspected invasion into the adjacent organs. However, the perioperative safety and oncological efficacy of this procedure merit further elucidation. Methods: Major databases were searched for studies evaluating EDP, and a meta-analysis was performed using fixed- or random-effects models. Results: Fifteen studies were included in the analysis. EDP was found to be associated with significantly greater incidence of postoperative pancreatic fistula overall and with major complications, re-explorations, mortality and readmissions. However, on pooled analysis of 3- and 5-year survival, EDP was found to be noninferior to standard distal pancreatectomy. Conclusion: EDP is feasible and may offer equivalent survival in highly selected patients but carries a higher risk of perioperative morbidity and mortality.
References
- 1. . Trends in pancreatic adenocarcinoma incidence and mortality in the United States in the last four decades; a SEER-based study. BMC Cancer 18(1), 688 (2018).
- 2. . Cancer statistics, 2020. CA Cancer J. Clin. 70(1), 7–30 (2020).
- 3. The impact of tumor location on resection and survival for pancreatic ductal adenocarcinoma. J. Surg. Res. 239, 60–66 (2019).
- 4. . Pancreatic ductal adenocarcinoma survival in South Australia: time trends and impact of tumour location. ANZ J. Surg. 91(5), 921–926 (2021).
- 5. . Tumors of the pancreatic body and tail. World J. Oncol. 1(2), 52–65 (2010).
- 6. Disparities in survival by stage after surgery between pancreatic head and body/tail in patients with nonmetastatic pancreatic cancer. PLOS ONE 14(12), e0226726 (2019).
- 7. . Head and body/tail pancreatic carcinomas are not the same tumors. Cancers 11(4), 497 (2019).
- 8. . Surgical management of pancreatic cancer – distal pancreatectomy. Semin. Oncol. 42(1), 110–122 (2015).
- 9. Prognosis of distal pancreatic cancers controlled by stage. Exp. Ther. Med. 20(2), 1091–1097 (2020).
- 10. . The anatomic location of pancreatic cancer is a prognostic factor for survival. HPB (Oxford) 10(5), 371–376 (2008).
- 11. Association of the location of pancreatic ductal adenocarcinoma (head, body, tail) with tumor stage, treatment, and survival: a population-based analysis. Acta Oncol. 57(12), 1655–1662 (2018).
- 12. . Pancreatic adenocarcinoma: complete tumor extirpation improves survival benefit despite larger tumors for patients who undergo distal pancreatectomy and splenectomy. J. Gastrointest. Surg. 16(2), 376–381 (2012).
- 13. The prognostic influence of intrapancreatic tumor location on survival after resection of pancreatic ductal adenocarcinoma. BMC Surg. 15, 123 (2015).
- 14. Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail. Br. J. Surg. 105(9), 1171–1181 (2018).
- 15. A margin-negative R0 resection accomplished with minimal postoperative complications is the surgeon’s contribution to long-term survival in pancreatic cancer. J. Gastrointest. Surg. 10(10), 1338–1345; discussion 45–46 (2006).
- 16. . Extended pancreatic resections and lymphadenectomy: an appraisal of the current evidence. World J. Gastrointest. Surg. 2(2), 39–46 (2010).
- 17. . Multivisceral pancreatic resections: worth the risk? Clin. Surg. 3, 1–7 (2018).
- 18. Evidence map of pancreatic surgery – a living systematic review with meta-analyses by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 170(5), 1517–1524 (2021).
- 19. Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 156(1), 1–14 (2014).
- 20. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372, n71 (2021).
- 21. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161(3), 584–591 (2017).
- 22. . Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 240(2), 205–213 (2004).
- 23. . Is extended resection for adenocarcinoma of the body or tail of the pancreas justified? J. Gastrointest. Surg. 7(8), 946–952; discussion 52 (2003).
- 24. . Distal pancreatectomy for resectable adenocarcinoma of the body and tail of the pancreas. J. Gastrointest. Surg. 9(7), 922–927 (2005).
- 25. Distal pancreatectomy is not associated with increased perioperative morbidity when performed as part of a multivisceral resection. J. Gastrointest. Surg. 12(12), 2177–2182 (2008).
- 26. Extended distal pancreatectomy for pancreatic adenocarcinoma with splenic vein thrombosis and/or adjacent organ invasion. Am. J. Surg. 209(3), 564–569 (2015).
- 27. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann. Surg. 245(4), 573–582 (2007).
- 28. . Distal pancreatectomy combined with multivisceral resection is associated with postoperative complication rates and survival comparable to those after standard procedures. J. Gastrointest. Surg. 22(9), 1549–1556 (2018).
- 29. Risk factors for surgical complications in distal pancreatectomy. Am. J. Surg. 200(3), 311–317 (2010).
- 30. . Multivisceral resection for adenocarcinoma of the pancreatic body and tail – a retrospective single-center analysis. World J. Surg. Oncol. 18(1), 218 (2020).
- 31. Outcome of distal pancreatectomy for pancreatic adenocarcinoma. Dig. Surg. 25(1), 32–38 (2008).
- 32. . Distal pancreatectomy for pancreatic carcinoma in the era of multimodal treatment. Br. J. Surg. 102(3), 229–236 (2015).
- 33. Distal pancreatectomy associated with multivisceral resection: results from a single centre experience. Langenbecks Arch. Surg. 402(3), 457–464 (2017).
- 34. Extended laparoscopic distal pancreatectomy for adenocarcinoma in the body and tail of the pancreas: a single-center experience. Langenbecks Arch. Surg. 403(8), 941–948 (2018).
- 35. Prognostic value of adjacent organ resection in patients with left-sided pancreatic ductal adenocarcinoma following distal pancreatectomy. J. Hepatobiliary Pancreat. Sci. 26(6), 227–234 (2019).
- 36. Distal pancreatectomy with multivisceral resection: a retrospective multicenter study – case series. Int. J. Surg. 82, 123–129 (2020).
- 37. Does long-term survival in patients with pancreatic cancer really exist? Results from the CONKO-001 study. J. Surg. Oncol. 108(6), 398–402 (2013).
- 38. Quality improvement of pancreatic surgery by centralization in the western part of The Netherlands. Ann. Surg. Oncol. 18(7), 1821–1829 (2011).
- 39. . The role of extended resection in pancreatic adenocarcinoma: is there good evidence-based justification? Pancreatology 4(6), 561–566 (2004).
- 40. Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study. HPB (Oxford) 11(8), 638–644 (2009).
- 41. Impact of neoadjuvant chemoradiation on pathologic response in patients with localized pancreatic cancer. Front Oncol. 10, 460 (2020).
- 42. . Curative resection for left-sided pancreatic malignancy. HPB (Oxford) 8(3), 211–215 (2006).
- 43. Impact of tumor size on the outcomes of patients with resectable distal pancreatic cancer: lessons learned from a series of 158 radical resections. Ann. Surg. Oncol. 29(1), 378–388 (2022).
- 44. Multivisceral resections in pancreatic cancer: identification of risk factors. World J. Surg. 35(12), 2756–2763 (2011).
- 45. Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann. Surg. 250(1), 81–87 (2009).
- 46. A safe technique for radical antegrade modular pancreatosplenectomy with venous resection for pancreatic cancer. J. Am. Coll. Surg. 217(5), e35–e39 (2013).
- 47. Outcomes and risk score for distal pancreatectomy with celiac axis resection (DP-CAR): an international multicenter analysis. Ann. Surg. Oncol. 26(3), 772–781 (2019).
- 48. . Thirty days are inadequate for assessing readmission following complex hepatopancreatobiliary procedures. Surg. Endosc. 33(8), 2508–2516 (2019).
- 49. . Is enhancing recovery after pancreatic cancer surgery even possible? Chin. Clin. Oncol. 10(5), 49 (2021).
- 50. . Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission. Future Oncol. 16(24), 1839–1849 (2020).
- 51. . Perioperative surgical home: a new scope for future anesthesiology. Korean J. Anesthesiol. 71(3), 175–181 (2018).
- 52. Outpatient virtual clinical encounters after complex surgery for cancer: a prospective pilot study of ‘TeleDischarge’. J. Surg. Res. 202(1), 196–203 (2016).
- 53. Outcomes of distal pancreatectomy for pancreatic ductal adenocarcinoma in The Netherlands: a nationwide retrospective analysis. Ann. Surg. Oncol. 23(2), 585–591 (2016).
- 54. Outcomes after extended pancreatectomy in patients with borderline resectable and locally advanced pancreatic cancer. Br. J. Surg. 103(12), 1683–1694 (2016).
- 55. . En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J. Gastrointest. Surg. 6(2), 147–157; discussion 57–58 (2002).
- 56. . Palliative resections versus palliative bypass procedures in pancreatic cancer – a systematic review. Am. J. Surg. 203(4), 496–502 (2012).
- 57. . Current Role of Surgery in Pancreatic Cancer With Synchronous Liver Metastasis. Cancer Control. 27(1), 1073274820976593 (2020).
doi: 10.1177/1073274820976593 . - 58. . Synchronous arterial resections in pancreatic cancer – still a matter of debate? Eur. J. Surg. Oncol. 47(2), 480–482 (2021).
- 59. . Neoadjuvant treatment in pancreatic cancer. Front Oncol. 10, 245 (2020).
doi: 10.3389/fonc.2020.00245 .