P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Background Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix. Methods TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO. Results Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p < 0.001) were independently associated with TO. Conclusions Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.

Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations

Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.

Vascular Resection in Perihilar Cholangiocarcinoma

Perihilar cholangiocarcinoma (phCC) is the most common type of cholangiocarcinoma, accounting for approximately 60 % of cases, followed by the distal and then the intrahepatic forms. There is not a staging system that allows comparation of all series and extract some conclusions to increase the long-survival rate in this dismal disease. The extension of the resection, which theoretically dependes on the type of phCC, is not closed subject. As surgery is the only known way to achieve a cure, many aggressive approachs have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, the surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.

Vascular resection for locally advanced pancreatic ductal adenocarcinoma: analysis of long-term outcomes from a single-centre series

Background Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis. Radical surgery is the best option for cure and, nowadays, it is performed by many surgeons also in cases of vascular infiltration. Whether this aggressive approach to a locally advanced PDAC produces a survival benefit is under debate. Most data in the literature come from retrospective comparative studies; therefore, it is still unclear if such an extensive surgery for an advanced cancer is justified. Methods A retrospective review of patients with PDAC treated at our institution over a 12-year period was performed. Data concerning patients’ characteristics, operative details, postoperative course, and long-term survival were retrieved from prospective databases and analysed. Factors associated with poor survival were assessed via Cox regression analysis. Results A total of 173 patients with PDAC were included in the analysis, 41 subjects underwent pancreatectomy with vascular resection for locally advanced disease, and in 132 patients, only a pancreatic resection was undertaken. Demographics, major comorbidities, and tumour characteristics were similar between the two groups. Length of surgery (P=0.0006), intraoperative blood transfusions (P<0.0001), and overall complications (P<0.0001) were significantly higher in the vascular resection group. Length of hospital stay (P=0.684) and 90-day mortality (P=0.575) were comparable between groups. Overall median survival (P= 0.717) and survival rates at 1, 3, and 5 years (P=0.964, P=0.500, and P=0.445, respectively) did not differ significantly between groups. Age ≥70 years and postoperative complications were independent predictors of lower survival. Conclusions Our study confirms that pancreatectomy with vascular resection for a locally advanced PDAC is a complex operation associated with a significant longer operating time that may increase morbidity; however, in selected patients, R0 margins can be obtained with an acceptable long-term survival rate. Older patients are less likely to benefit from surgery.