K. S. Cools2, H. J. Kim2, J. J. Yeh2, H. K. Sanoff3, K. B. Stitzenberg2 2University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Department Of Medicine,Chapel Hill, NC, USA
Introduction:
Although surgical resection remains the only potentially curative treatment for pancreas cancer, neoadjuvant chemotherapy and/or radiation therapy has been increasingly employed to try to downstage patients with borderline resectable tumors. Still, there is a paucity of literature examining outcomes at the population level, for patients who do and do not receive neoadjuvant therapy. The existing studies highlight single/few center experiences, with mixed results. The aim of this study was to compare on a population level, the postoperative morbidity and mortality after pancreaticoduodenectomy (PD) in patients undergoing neoadjuvant therapy versus initial surgery for pancreatic ductal adenocarcinoma (PDA).
Methods:
Using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA between 2014 and 2015. This database consists of pancreas-specific outcomes from 106 centers in the United States. Patients were grouped based on having received neoadjuvant therapy within 90-days of PD. We used bivariable and multivariable analyses to compare postoperative outcomes between the groups.
Results:
A total of 3,758 patients with PDA underwent PD; 930 (24.7%) received neoadjuvant therapy (13.5% chemotherapy only, 0.8% radiation only, and 10.4% chemoradiation). Those in the neoadjuvant group were more likely to have preoperative biliary stenting (66.2% vs 61.8%, p=0.015), a major vein resection (35.8% vs 17.5%, p<0.001), and longer operating time (413 min vs 364 min, p<0.001). At the time of surgery, those in the neoadjuvant group also had more T1 tumors (10.9% vs 5.1%, p<0.001) and fewer nodes positive (N0 49% vs 28%, p<0.001). There were no differences in 30-day postoperative mortality (1.7% vs 2%, p=0.616) or overall complications (55.9% vs 55.2%, p=0.689). On multivariate analysis, patients who received neoadjuvant therapy had a lower likelihood of pancreatic fistula (OR 0.67, 95% CI 0.49-0.92, p<0.001). On multivariate analysis to identify factors associated with pancreatic fistulas, independent predictors included having initial surgery (OR 1.44, 95% CI 1.07-1.95), preoperative biliary stenting (OR 1.3, 95% CI 1.02-1.7), soft pancreatic tissue (OR 2.96, 95% CI 2.32-3.78), longer operative times (OR 1.06, 95% CI 1.0-1.12), and a normal preoperative albumin (OR 1.41, 95% CI 1.08-1.85).
Conclusion:
Using the robust NSQIP database of over 100 centers, we found that neoadjuvant therapy does not increase the overall postoperative morbidity or mortality of a PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.
