Werner Hartwig1, Charles M Vollmer2, Abe Fingerhut3, Charles J Yeo4, John P Neoptolemos5, Mustapha Adham6, Ake Andrén-Sandberg7, Horacio J Asbun8, Claudio Bassi9, Max Bockhorn10, Richard Charnley11, Kevin C Conlon12, Christos Dervenis13, Laureano Fernandez-Cruz14, Helmut Friess15, Dirk J Gouma16, Clem W Imrie17, Keith D Lillemoe18, Miroslav N Milićević19, Marco Montorsi20, Shailesh V Shrikhande21, Yogesh K Vashist10, Jakob R Izbicki10, Markus W Büchler22. 1. Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany. 2. Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. 3. Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France. 4. Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. 5. Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. 6. Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France. 7. Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. 8. Department of General Surgery, Mayo Clinic, Jacksonville, FL. 9. Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. 10. Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 11. Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. 12. Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. 13. Department of First Surgery, Agia Olga Hospital, Athens, Greece. 14. Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. 15. Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. 16. Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. 17. Academic Unit of Surgery, University of Glasgow, Glasgow, UK. 18. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. 19. First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. 20. Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. 21. Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. 22. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. Electronic address: markus.buechler@med.uni-heidelberg.de.
Abstract
BACKGROUND: Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can involve adjacent organs, "extended" pancreatectomy that includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. RESULTS: Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit, and hospital morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared with standard resections but appears to be better compared with bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. CONCLUSION: Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established that are crucial for comparison of results of future trials across different practices and countries, in particular for those using neoadjuvant therapy.
BACKGROUND: Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can involve adjacent organs, "extended" pancreatectomy that includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. RESULTS: Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit, and hospital morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared with standard resections but appears to be better compared with bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. CONCLUSION: Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established that are crucial for comparison of results of future trials across different practices and countries, in particular for those using neoadjuvant therapy.