Liver-directed therapy for hepatic metastases in patients undergoing pancreaticoduodenectomy: a dual-center analysis.
OBJECTIVE
To analyze the perioperative and long-term outcomes of patients undergoing liver-directed therapy after pancreaticoduodenectomy in a large dual-center cohort of patients.


BACKGROUND
Although aggressive liver-directed therapy may be beneficial, liver-directed therapy may be associated with a high risk of complications after pancreaticoduodenectomy.


METHODS
Of 5025 patients who underwent pancreaticoduodenectomy at the Johns Hopkins Hospital and the Mayo Clinic between 1970 and 2008, 126 (2.5%), patients were identified who were also treated with either simultaneous or staged liver-directed therapy. Data on demographics, primary tumor, and hepatic metastasis characteristics, as well as details of the liver-directed therapy were collected and analyzed.


RESULTS
Primary tumor histology included neuroendocrine carcinoma (34.9%), pancreatic ductal adenocarcinoma (33.4%), distal cholangiocarcinoma (8.7%), ampullary carcinoma (7.1%), duodenal carcinoma (4.0%), or other (11.9%). Liver-directed therapies included hepatic resection alone (45.2%), hepatic resection plus ablation (11.1%), ablation alone (7.9%), transarterial chemoembolization (9.5%), and whole-liver irradiation (22.2%). The overall morbidity following liver-directed therapy was 34.1% and overall mortality was 2.4%. Patients undergoing staged liver-directed therapy (14.5%) versus simultaneous pancreaticoduodenectomy plus liver-directed therapy (7.0%) were more likely to develop a liver abscess (P < 0.05). Of those patients who developed complications, the majority (55.8%) were major (Clavien grade >or=3).


CONCLUSIONS
Pancreaticoduodenectomy plus liver-directed therapy is associated with considerable morbidity. The incidence of hepatic abscess is increased in patients undergoing staged pancreaticoduodenectomy followed by liver-directed therapy.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Mechteld C
MC
De Jong
Michael B
MB
Farnell
Guido
G
Sclabas
Steven C
SC
Cunningham
John L
JL
Cameron
Jean-Francois
JF
Geschwind
Christopher L
CL
Wolfgang
Joseph M
JM
Herman
Barish H
BH
Edil
Michael A
MA
Choti
Richard D
RD
Schulick
David M
DM
Nagorney
Timothy M
TM
Pawlik
D000230:Adenocarcinoma / Q000473:pathology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000473:pathology; D001653:Bile Ducts, Intrahepatic; D002277:Carcinoma / Q000473:pathology; D044584:Carcinoma, Ductal / Q000473:pathology; D018278:Carcinoma, Neuroendocrine / Q000473:pathology; D017115:Catheter Ablation; D016461:Chemoembolization, Therapeutic; D018281:Cholangiocarcinoma / Q000473:pathology; D004379:Duodenal Neoplasms / Q000473:pathology / Q000556:secondary; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008099:Liver / Q000528:radiation effects* / Q000601:surgery*; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000473:pathology; D016577:Pancreaticoduodenectomy