title: Crossing the Rubicon: when pancreatic resection with curative intent ends in an R2 status. Impact of "desmoplastic pseudo-pancreatitis" and anatomical site of irresectability.
abstract: OBJECTIVE
  To analyze the impact of pancreatitis-mimicking, concomitant alterations on intraoperative assessment of curative resectability, the anatomical site of irresectability, and outcome after nonintentional R2 resection in pancreatic cancer.
  
  
  METHODS
  Of 1,099 patients subjected to pancreatic resection for cancer, 40 (4%) underwent R2 resection (group A). The site where tumors turned out to be irresectable and the coincident presence of potentially misleading, fibro-desmoplastic alterations were analyzed. Outcome after resection was compared with 40 bypass patients matched for age, gender, histopathology, and use of additive chemotherapy (group B).
  
  
  RESULTS
  R2 resection was due to misjudgment regarding resectability in 38 patients (95%) and to uncontrollable hemorrhage in 2 patients (5%). Group A patients had significantly longer operative times (P < 0.0001), required more blood units (P < 0.0001), and had longer hospital stay than group B patients (P = 0.049). Despite a significantly higher relaparotomy rate of 20% (n = 8) in group A versus 5% (n = 2) in group B, perioperative mortality was equal (n = 2, each). Median survival was 11.5 months in group A and 7.5 months in group B (P = 0.014). "Pancreatitis-like" lesions were assessed in 70% (n = 28/40, group A) and 25% (10/40, group B; P = 0.014). The superior mesenteric artery proximal to its jejunal branches was the most likely site of irresectability (60%), followed by its peripheral course (22.5%) and the lower aspects of the celiac trunk (17.5%).
  
  
  CONCLUSIONS
  Concomitant "pancreatitis-like" alterations hamper the assessment of local resectability in pancreatic cancer. Although palliative resection results in elevated perioperative morbidity compared with bypass procedures, mortality is equal, while survival is prolonged.
authors.affiliation: Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany. m.bockhorn@uke.uni-hamburg.de
authors.forename: Maximilian
authors.initials: M
authors.lastname: Bockhorn
authors.forename: Guellue
authors.initials: G
authors.lastname: Cataldegirmen
authors.forename: Asad
authors.initials: A
authors.lastname: Kutup
authors.forename: Andreas
authors.initials: A
authors.lastname: Marx
authors.forename: Christoph
authors.initials: C
authors.lastname: Burdelski
authors.forename: Jogesh K
authors.initials: JK
authors.lastname: Vashist
authors.forename: Oliver
authors.initials: O
authors.lastname: Mann
authors.forename: Lena
authors.initials: L
authors.lastname: Liebl
authors.forename: Alexandra
authors.initials: A
authors.lastname: König
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.forename: Emre F
authors.initials: EF
authors.lastname: Yekebas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery*