Efficacy and safety of laparoscopic radical resection following neoadjuvant therapy for pancreatic ductal adenocarcinoma: A retrospective study

Abstract

Background: Multiple studies have demonstrated that neoadjuvant chemotherapy (NACT) can prolong the overall survival of pancreatic ductal adenocarcinoma (PDAC) patients. However, most studies have focused on open surgery following NACT.

Aim: To investigate the efficacy and safety of laparoscopic radical resection following NACT for PDAC.

Methods: We retrospectively analyzed the clinical data of 15 patients with pathologically confirmed PDAC who received NACT followed by laparoscopic radical surgery in our hospital from December 2019 to April 2022. All patients underwent abdominal contrast-enhanced computed tomography (CT) and positron emission tomography-CT before surgery to accurately assess tumor stage and exclude distant metastasis.

Results: All 15 patients with pancreatic cancer were successfully converted to surgical resection after NACT, including 8 patients with pancreatic head cancer and 7 patients with pancreatic body and tail cancer. Among them, 13 patients received the nab-paclitaxel plus gemcitabine regimen (gemcitabine 1000 mg/m² plus nab-paclitaxel 125 mg/m² on days 1, 8, and 15 every 4 wk) and 2 patients received the modified FOLFIRINOX regimen (intravenous oxaliplatin 68 mg/m², irinotecan 135 mg/m², and leucovorin 400 mg/m² on day 1 and fluorouracil 400 mg/m² on day 1, followed by 46-h continuous infusion of fluorouracil 2400 mg/m²). After each treatment cycle, abdominal CT, tumor markers, and circulating tumor cell counts were reviewed to evaluate the treatment efficacy. All 15 patients achieved partial remission. The surgical procedures included laparoscopic pancreaticoduodenectomy (LPD, n = 8) and laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS, n = 7). None of them were converted to a laparotomy. One patient with pancreatic head carcinoma was found to have portal vein involvement during the operation, and LPD combined with vascular resection and reconstruction was performed. The amount of blood loss and operation times of L-RAMPS vs LPD were 435.71 ± 32.37 mL vs 343.75 ± 145.01 mL and 272.52 ± 49.14 min vs 444.38 ± 68.63 min, respectively. The number of dissected lymph nodes was 16.87 ± 4.10, and 3 patients had positive lymph nodes. One patient developed grade B postoperative pancreatic fistula (POPF) after L-RAMPS, and one patient experienced jaundice after LPD. None of the patients died after surgery. As of April 2022, progressive disease was noted in 4 patients, 2 patients had liver metastasis, and one had both liver metastasis and lymph node metastasis and died during the follow-up period.

Conclusion: Laparoscopic radical resection of PDAC after NACT is safe and effective if it is performed by a surgeon with rich experience in LPD and in a large center of pancreatic surgery.

Keywords: Complications; Laparoscopic pancreaticoduodenectomy; Laparoscopic radical antegrade modular pancreatosplenectomy; Neoadjuvant chemotherapy; Pancreatic ductal adenocarcinoma.

Figure 1

Computed tomography changes in pancreatic cancer before and after neoadjuvant chemotherapy. A-C: Computed tomography (CT) before neoadjuvant chemotherapy revealed pancreatic cancer with multiple lymph node metastases (red arrow); D: Pancreatic cancer invaded the portal vein wall (red arrow); E-G: After 2 cycles of neoadjuvant chemotherapy, CT showed a decreased diameter of pancreatic cancer and a reduced number of lymph nodes (red arrow); H and I: After 4 cycles of neoadjuvant chemotherapy, CT showed an obviously decreased diameter of pancreatic cancer and a reduced number of retroperitoneal lymph nodes; J: The superior mesenteric vein had a regular shape.

Figure 2

Kaplan-Meier curves of overall survival and disease-free survival. A: The 1- and 2-year survival rates were both 50%; B: The 1- and 2-year disease-free survival rates were 60.00% and 40.00%, respectively.