title: Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma.
abstract: BACKGROUND
  Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection.
  
  
  OBJECTIVE
  The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma.
  
  
  METHODS
  We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX.
  
  
  RESULTS
  We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months.
  
  
  CONCLUSIONS
  Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.
authors.affiliation: Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA. harish.lavu@jefferson.edu
authors.forename: Harish
authors.initials: H
authors.lastname: Lavu
authors.forename: Andres A
authors.initials: AA
authors.lastname: Mascaro
authors.forename: Dane R
authors.initials: DR
authors.lastname: Grenda
authors.forename: Patricia K
authors.initials: PK
authors.lastname: Sauter
authors.forename: Benjamin E
authors.initials: BE
authors.lastname: Leiby
authors.forename: Sean P
authors.initials: SP
authors.lastname: Croker
authors.forename: Agnes
authors.initials: A
authors.lastname: Witkiewicz
authors.forename: Adam C
authors.initials: AC
authors.lastname: Berger
authors.forename: Ernest L
authors.initials: EL
authors.lastname: Rosato
authors.forename: Eugene P
authors.initials: EP
authors.lastname: Kennedy
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D021441:Carcinoma, Pancreatic Ductal / Q000401:mortality / Q000601:surgery*; D013505:Digestive System Surgical Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods / Q000401:mortality