M Korrel1, S Lof1,2, J van Hilst1,3, A Alseidi4, U Boggi5, O R Busch1, S van Dieren1, B Edwin6, D Fuks7, T Hackert8, T Keck9, I Khatkov10, G Malleo11, I Poves12, M A Sahakyan6,13, C Bassi11, M Abu Hilal14, M G Besselink15. 1. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 2. Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy. 3. Department of Surgery, OLVG Oost, Amsterdam, The Netherlands. 4. Division of Hepatopancreatobiliary and Endocrine Surgery, Virginia Mason Medical Center, Seattle, WA, USA. 5. Division of General and Transplant Surgery, University of Pisa, Pisa, Italy. 6. Department of HPB Surgery, The Intervention Center, Institute for Clinical Medicine, Oslo University Hospital, Oslo, Norway. 7. Department of Surgery, Institut Mutualiste Montsouris, Paris, France. 8. Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany. 9. Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. 10. Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation. 11. Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy. 12. Department of Surgery, Hospital del Mar, Barcelona, Spain. 13. Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia. 14. Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy. abuhilal9@gmail.com. 15. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. m.g.besselink@amsterdamumc.nl.
Abstract
BACKGROUND: Surgical factors, including resection of Gerota's fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique. PATIENTS AND METHODS: Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007-2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota's fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach. RESULTS: Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5-31 months] and median survival period of 30 months [95% confidence interval (CI), 27-33 months] were included. Gerota's fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival. CONCLUSIONS: This international cohort identified Gerota's fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota's fascia resection in their routine surgical approach.
BACKGROUND: Surgical factors, including resection of Gerota's fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique. PATIENTS AND METHODS: Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007-2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota's fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach. RESULTS: Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5-31 months] and median survival period of 30 months [95% confidence interval (CI), 27-33 months] were included. Gerota's fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival. CONCLUSIONS: This international cohort identified Gerota's fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota's fascia resection in their routine surgical approach.
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