Role of Extended Resection in Pancreatic Cancer

Pedrazzoli et al.

Yeo et al.

Farnell et al.

Nimura et al.

Jang et al.

Standard operation

Anterior/posterior pancreatoduodenal

Pyloric

Biliary duct

Superior/inferior pancreatic head and body

Anterior/posterior pancreaticoduodenal

Hepatoduodenal ligament

Right lateral aspect of the SMA and SMV

Gastric lesser/greater curvature

Pyloric

Right of the hepatoduodenal ligament

Anterior/posterior pancreatoduodenal

Right of the SMA

Anterior to the CHA

Anterior/posterior pancreatoduodenal

Bile duct and cystic duct

Extended operation

Hepatic hilum

Along the aorta from the diaphragmatic hiatus to the IMA

Laterally to both renal hilus

Gastric lesser/greater curvature

Superior/inferior pyloric

Celiac origin

Celiac to left renal vein

Left renal vein to IMA

Between bilateral renal hilum

Hepatoduodenal ligament skeletonization up to the liver

Hepatic artery and celiac axis

Paraaortic from celiac axis to IPM

Circumferential dissection of the SMA

Common hepatic artery

Celiac artery

Hepatoduodenal ligament skeletonization

SMA

Paraaortic from the origin of celiac axis to IMA

Common hepatic artery

Celiac axis

Hepatoduodenal ligament skeletonization

SMA

Paraaortic between celiac axis and IMA

Nerve plexus dissection in extended operation

Circumferentially around the CHA and SMA, semicircumferentially on the right lateral aspect of the celiac axis

Right side of the celiac axis and SMA semicircumferentially

In two RCTs, dissection around the SMA was considered as nerve plexus dissection. Diarrhea rates were reported between 42–84% after circumferential dissection and 15% after semicircumferential dissection of the SMA nerve plexus. However, R0 resection rate and overall survival was not affected by the extent of SMA nerve plexus dissection. Therefore, circumferential dissection of the SMA is not oncologically necessary, but only worsens the QOL after pancreatoduodenectomy.

Operative outcomes according to surgical extents are summarized in Table 21.2. Mean operative time was significantly longer in extended pancreatoduodenectomy (EPD) in four studies. Blood transfusion rate was higher in extended surgery compared to standard pancreatoduodenectomy (SPD) in one trial. R0 resection rates were similar in the SPD (72.5–94.1%) and EPD (78.0–93.0%) groups. In all five studies, the number of retrieved lymph nodes was significantly higher in the EPD than in the SPD group. However, lymph node metastasis rates in all five studies were similar in patients who underwent EPD (43.2–68.0%) and SPD (45.9–68.7%) [8, 19–23].

Table 21.2

Operative outcome of five RCTs according to type of surgery

		Pedrazzoli et al.		Yeo et al.		Farnell et al.		Nimura et al.		Jang et al.
		SPD	EPD	SPD	EPD	SPD	EPD	SPD	EPD	SPD	EPD
N		40	41	146	148	40	39	51	50	83	86
Operative time (min)	Mean ± SEM	371.9 ± 49.8	396.7 ± 49.9	354	384	378	450	426	547	355.5 ± 12.4	419.6 ± 13.0
Blood transfusion (U)	Mean ± SD	1.95 ± 0.2	2.07 ± 0.2	0.5 ± 0.1	0.5 ± 0.1	22%	44%	2.1	2.4	0.1 ± 0.05	0.25 ± 0.09
PD/PPPD/SSPPD	N	20/20/0	18/23/0	21/125/0	148/0/0	40/0/0	39/0/0	13/19/19	11/23/16	21/62/0	26/60/0
Portal vein resection	N(%)	–	–	4(3%)	4(3%)	(23%)	(21%)	24(47%)	24(48%)	17(20.5%)	23(26.7%)
No. of lymph nodes retrieved	Mean	13.3	19.8	17.0	28.5	15	34	13.3	40.1	17.3	33.7
LN(+)(%)	N(%)	24(60.0%)	24(58.5%)	67(45.9%)	64(43.2%)	(55%)	(68%)	32(63%)	30(60%)	57(68.7%)	57(66.3%)
R0 resection (%)	N(%)	29(72.5%)	32(78.0%)	128(88%)	138(93%)	(76%)	(82%)	48(94.1%)	45(90%)	71(85.5%)	78(90.7%)
Postoperative hospital stay (days)	Mean ± SD	22.7 ± 1.4^a	19.3 ± 1.1^a	11.3 ± 0.5^a	14.3 ± 0.8^a	13	16	43.8	42.4	19.7 ± 9.4	22.8 ± 17.1

^aStandard error of means

Meta-analysis of the five RCTs showed that delayed gastric emptying and pancreatic fistula rates tend to be higher in patients who underwent EPD. However, meta-analysis of each morbidity using a random effects model revealed no significant differences. The rate of postoperative diarrhea (17.3% vs. 6.7%, p = 0.08) and overall postoperative morbidity (38.8% vs. 30.3%, p = 0.160) tended to be higher in patients who underwent EPD (Fig. 21.1). The odds ratio for mortality in the EPD group was 1.02 (95% CI, 0.38–2.69), but the difference was not statistically significant.