Second-look operation for unresectable pancreatic ductal adenocarcinoma at a high-volume center

Abstract

Background: The value of re-exploration for pancreatic ductal adenocarcinoma after the initial diagnosis of unresectability is unclear.

Methods: In this study, we analyzed 33 patients who were re-explored after an initial diagnosis of unresectability.

Results: At the time of reoperation, a resectable tumor was found in 18 patients: therefore, 15 pancreaticoduodenectomies, two total pancreatectomies and one left resection were performed with three vascular resections. Morbidity and mortality rates for the cohort were 6/33 and 1/33, without significant differences between resectable and nonresectable patients. Length of stay, duration of operation, and blood loss were significantly increased in the resection group. Kaplan-Meier survival analysis demonstrated increased median survival for resected patients (1078 days after the initial operation versus 547 days in the group of unresectable patients; p = 0.018). Analysis of the reasons against initial resection showed that, if the patients had been sent to a tertiary referral center for pancreatic surgery, a different decision in favor of resection would probably have been made in 14 out of 33 patients. A review of 10 published reports on reoperation for pancreatic cancer revealed results comparable to our study in terms of low morbidity and mortality as well as a survival benefit.

Conclusions: Reoperation for pancreatic ductal adenocarcinoma that is initially deemed unresectable can be safely performed in a selected group of patients by experienced surgeons, supporting the concept of patient centralization in pancreatic surgery. Resection at the second operation may confer a survival benefit even when the initial findings preclude a potentially curative approach.

FIG. 1.

Kaplan–Meier survival curve of re-explored patients after initial operation. Comparison of the survival curves of re-explored, resected patients (n = 17; one excluded due to postoperative mortality; red) and re-explored, unresectable patients (n = 15; black). A log-rank test demonstrated significantly increased survival in the resected patients (P = 0.018).

FIG 2.

Survival curves of re-explored, resected patients and 572 primarily resected pancreatic ductal adenocarcinoma (PDAC) patients. Comparison of the survival curves of re-explored, resected patients (n = 18; red) and a control cohort of 572 patients (black) who were initially resected revealed no differences regarding survival (P = 0.2514).

FIG. 3.

Overall survival of re-explored, unresectable patients and 256 unresectable patients. The survival of a control cohort of 256 PDAC patients who were unresectable (n = 265) was compared with re-explored, unresectable patients (n = 15; red), revealing no differences in survival (P = 0.45).