Conventional partial pancreatoduodenectomy versus an uncinate first, extended partial pancreatoduodenectomy approach for the resection of pancreatic head cancer: the randomized, controlled PancER trial

TL;DR

This study compares two surgical approaches for pancreatic cancer and finds that a more radical procedure does not significantly improve cancer removal rates but is being used to develop an even more extensive technique.

Contribution

The study introduces a more radical PD approach along the SMA and serves as pilot data for a new TRIANGLE operation trial.

Findings

Extended PD increased R0 resection rates by 10% but not significantly.

Extended PD led to more reported diarrhea symptoms after 30 days.

The TRIANGLE operation is now being evaluated based on this trial's findings.

Abstract

After pancreatoduodenectomy (PD) due to pancreatic cancer, recurrence is frequent in almost half of the patients. The rate of R0 resections is associated with the probability of local recurrence and overall survival. A potential intervention to improve the rate of R0 resections is a more radical resection along the superior mesenteric artery (SMA); however, randomized data of such an approach are lacking. Therefore, we conducted the randomized, controlled PancER trial to evaluate the effect of an extended PD compared with conventional PD.

Patients were randomized to either an extended PD consisting of a modified Kocher maneuver with partial resection of the prerenal fascia, an uncinate process first approach with systematic mesopancreatic dissection along the SMA equivalent to level III dissection according to Inoue, or conventional PD. The primary endpoint, rate of R0 resections, and other perioperative outcomes were compared.

A total of 50 patients were randomly assigned to extended PD (n=24) or conventional PD (n=26). R0 resections were 10 % more frequent in the extended PD group than in the conventional group (75.0 vs. 64.7 %), which was not statistically significant (p=0.59). Patients self-reported more diarrhea symptoms following extended PD after 30 days (p<0.01). Other perioperative outcomes as well as long-term outcomes were comparable between the two groups.

The PancER trial shows that extended PD with more radical resection along the SMA can be performed with comparable perioperative outcomes to conventional PD. Although the intervention improved the R0 resection rate by 10 %, this increase was below expectation. Therefore, an even more radical PD resection technique involving not only the SMA but also the celiac and hepatic artery (TRIANGLE operation) was developed at Heidelberg University. The TRIANGLE operation is currently being evaluated in a randomized controlled multicenter trial. The results of the PancER trial served as pilot data for this subsequent study.

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