Outcomes and risks in palliative pancreatic surgery: an analysis of the German StuDoQ|Pancreas registry

[Patient safety in palliative surgery]

Palliative surgery aims to improve the quality of life for patients with incurable diseases. This patient group is vulnerable due to the underlying illness, prior treatment and comorbidities, which increase the risk of complications that can negatively impact the course of the disease and quality of life. Palliative surgical interventions often provide effective long-term symptom control but are more invasive than conservative, interventional endoscopic or interventional radiological alternatives. This article exemplary discusses frequent palliative visceral surgical procedures and less invasive alternatives. In practice, a close interdisciplinary collaboration, open and realistic communication, optimized perioperative care and in particular the minimization of cumulative invasiveness are crucial to maximize the quality of life and safety for oncological patients.

Definition of Palliative Surgery in Cancer Care: A Systematic Review

Palliative surgery is commonly performed in cancer centers worldwide. Yet, there is little agreement on the definition of palliative surgery or its relevant outcomes. This systematic review sought to characterize the definitions of palliative surgery and outcomes for patients with cancer undergoing thoraco-abdominal procedures. Following PRISMA guidelines, we conducted a search using PubMed, EMBASE and CINAHL databases to identify English-language publications between August 1, 2005, and December 31, 2023 reporting palliative thoraco-abdominal procedures for patients with cancer. Definitions of palliative surgery were coded and analyzed using an inductive approach. Outcomes were classified according to an outcome measures hierarchy. Among 92 articles met inclusion criteria and four themes emerged in how palliative surgery was defined throughout the literature: prognosis (incurable cancer diagnosis), purpose (intent to treat symptoms or improve quality of life), procedure type (specific operative interventions), or persistent disease following surgery (incomplete cytoreduction). Survival (90%) and perioperative complications/morbidity (72%) were the most commonly reported outcomes, whereas symptom relief, quality of life, and sustainability of success were infrequently reported. Definitions of palliative surgery vary across studies of patients with cancer undergoing thoracic or abdominal procedures and measured outcomes often do not align with the intent of surgery.

Impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX: Trans-Atlantic Pancreatic Surgery (TAPS) Consortium study

BACKGROUND

Surgery in selected patients with locally advanced pancreatic cancer after induction chemotherapy may have drawbacks related to surgical risks and breaks or delays in oncological treatment, in particular when curative intent resection is not possible (that is non-therapeutic laparotomy). The aim of this study was to assess the incidence and oncological impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX chemotherapy.

METHODS

This was a retrospective international multicentre study including patients diagnosed with pathology-proven locally advanced pancreatic cancer treated with at least one cycle of (m)FOLFIRINOX (2012-2019). Patients undergoing a non-therapeutic laparotomy (group A) were compared with those not undergoing surgery (group B) and those undergoing resection (group C).

RESULTS

Overall, 663 patients with locally advanced pancreatic cancer were included (67 patients (10.1%) in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C). A non-therapeutic laparotomy occurred in 28.2% of all explorations (67 of 238), with occult metastases in 30 patients (30 of 67, 44.8%) and a 90-day mortality rate of 3.0% (2 of 67). Administration of palliative therapy (65.9% versus 73.1%; P = 0.307) and median overall survival (20.4 [95% c.i. 15.9 to 27.3] versus 20.2 [95% c.i. 19.1 to 22.7] months; P = 0.752) did not differ between group A and group B respectively. The median overall survival in group C was 36.1 (95% c.i. 30.5 to 41.2) months. The 5-year overall survival rates were 11.4%, 8.7%, and 24.7% in group A, group B, and group C, respectively. Compared with group B, non-therapeutic laparotomy (group A) was not associated with reduced overall survival (HR = 0.88 [95% c.i. 0.61 to 1.27]).

CONCLUSION

More than a quarter of surgically explored patients with locally advanced pancreatic cancer after induction (m)FOLFIRINOX did not undergo a resection. Such non-therapeutic laparotomy does not appear to substantially impact oncological outcomes.

"Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022

Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.