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Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR): An International Multicenter Analysis

Sjors Klompmaker MD, Niek A. Peters MD, Jony van Hilst MD, Claudio Bassi MD, Ugo Boggi MD, PhD, Olivier R. Busch MD, PhD, Willem Niesen MD, Thomas M. Van Gulik MD, PhD, Ammar A. Javed MD, Jorg Kleeff MD, FACS, Manabu Kawai MD, PhD, Mickael Lesurtel MD, PhD, Carlo Lombardo MD, A. James Moser MD, FACS, Ken-ichi Okada MD, PhD, Irinel Popescu MD, Raj Prasad MD, Roberto Salvia MD, Alain Sauvanet MD, Ch
Hepatobiliary Tumors
Volume 26, Issue 3 / March , 2019

Abstract

Background

Distal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes.

Methods

This multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000–2016) and three very-high-volume international centers in the United States and Japan (model validation 2004–2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival.

Results

For 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2–11%) at 5 high-volume (≥ 1 DP-CAR/year) and 18% (95 CI, 9–30%) at 18 low-volume DP-CAR centers (P = 0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P = 0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19 months (95 CI, 15–25 months).

Conclusions

When performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor.

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