Does the Artery-first Approach Improve the Rate of R0 Resection in Pancreatoduodenectomy?
- 1 November 2019
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Annals of Surgery
- Vol. 270 (5), 738-746
- https://doi.org/10.1097/sla.0000000000003535
Abstract
To compare the rates of R0 resection in pancreatoduodenectomy (PD) for pancreatic and periampullary malignant tumors by means of standard (ST-PD) versus artery-first approach (AFA-PD). Standardized histological examination of PD specimens has shown that most pancreatic resections thought to be R0 resections are R1. “Artery-first approach” is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. To date, studies comparing AFA-PD versus ST-PD are retrospective cohort or case-control studies. A multicenter, randomized, controlled trial was conducted in 10 University Hospitals (NCT02803814, ClinicalTrials.gov). Eligible patients were those who presented with pancreatic head adenocarcinoma and periampullary tumors (ampulloma, distal cholangiocarcinoma, duodenal adenocarcinoma). Assignment to each group (ST-PD or AFA-PD) was randomized by blocks and stratified by centers. The primary end-point was the rate of tumor-free resection margins (R0); secondary end-points were postoperative complications and mortality. One hundred seventy-nine patients were assessed for eligibility and 176 randomized. After exclusions, the final analysis included 75 ST-PD and 78 AFA-PD. R0 resection rates were 77.3% (95% CI: 68.4–87.4) with ST-PD and 67.9% (95% CI: 58.3–79.1) with AFA-PD, P=0.194. There were no significant differences in postoperative complication rates, overall 73.3% versus 67.9%, and perioperative mortality 4% versus 6.4%. Despite theoretical oncological advantages associated with AFA-PD and evidence coming from low-level studies, this multicenter, randomized, controlled trial has found no difference neither in R0 resection rates nor in postoperative complications in patients undergoing ST-PD versus AFA-PD for pancreatic head adenocarcinoma and other periampullary tumors.Keywords
This publication has 46 references indexed in Scilit:
- The Impact of Positive Resection Margins on Survival and Recurrence Following Resection and Adjuvant Chemotherapy for Pancreatic Ductal AdenocarcinomaAnnals of Surgery, 2019
- Incidence and comparative outcomes of periampullary cancer: A population‐based analysis demonstrating improved outcomes and increased use of adjuvant therapy from 2004 to 2012Journal of Surgical Oncology, 2018
- Dilemmas for the pathologist in the oncologic assessment of pancreatoduodenectomy specimensVirchows Archiv A Pathological Anatomy and Histopathology, 2018
- Pancreatic Cancer SurgeryAnnals of Surgery, 2017
- Meta-analysis of radical resection rates and margin assessment in pancreatic cancerBritish Journal of Surgery, 2015
- The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over TimeHPB Surgery, 2014
- Impact of margin status on survival following pancreatoduodenectomy for cancer: the Leeds Pathology Protocol (LEEPP)HPB, 2009
- Results of Pancreaticoduodenectomy in Patients With Periampullary AdenocarcinomaAnnals of Surgery, 2008
- Most Pancreatic Cancer Resections are R1 ResectionsAnnals of Surgical Oncology, 2008
- Redefining the R1 resection in pancreatic cancerBritish Journal of Surgery, 2006