In the era of effective chemotherapy on pancreatic ductal adenocarcinoma (PDAC) with distant metastasis, data on the effects of metastatectomy are lacking. So, we investigated the effect of metastatectomy on survival after metastasis in PDAC patients with isolated lung metastasis. This retrospective study analyzed 1342 patients who were histologically diagnosed with PDAC with distant metastasis from January 2007 to December 2018, of which 83 patients had isolated pulmonary metastasis. Additionally, 4263 patients were extracted from the National Cancer Database (NCDB) and analyzed. Log-rank test and Kaplan−Meier survival analysis were used to analyze survival after metastasis. The five-year survival rate was significantly higher in patients who underwent pulmonary metastatectomy than in those who received only chemotherapy or supportive treatment (60.6% vs. 6.2% vs. 0.0%, p < 0.001). A similar trend was observed in the NCDB (two-year survival rate, 27.4% vs. 15.8% vs. 4.7%, p < 0.001). In the multivariate analysis, lung lesion multiplicity (hazard ratio (HR) = 2.004, p = 0.017), metastatectomy (HR = 0.278, p = 0.036), chemotherapy (HR = 0.434, p = 0.024), and chemotherapy cycles (HR = 0.300, p < 0.001) had significant effects on survival. Metastatectomy with primary pancreatic lesions is recommended with effective chemotherapy in PDAC patients with isolated lung metastasis.

Background: Thoracic epidural analgesia (TEA), once the standard for pain management in major abdominal operations, is associated with postoperative complications, making preperitoneal continuous wound infiltration (CWI) a promising alternative. This study aimed to compare the effectiveness of CWI and TEA in managing postoperative pain after open pancreatoduodenectomy. Methods: In a single-centre, randomized, open-label non-inferiority trial, adult patients undergoing elective open pancreatoduodenectomy were assigned to either CWI or TEA for pain management. The primary outcomes were mean pain scores at rest on the first 3 postoperative days (PODs), using an 11-point numeric rating scale, with a non-inferiority margin of 1 point or less. Secondary outcomes included pain scores at rest and during coughing on PODs 1, 2, and 3; total opioid consumption; incidence of postoperative complications; quality of postoperative recovery; and duration of hospital stay. Results: Among the 134 patients analysed (CWI 70, TEA 64), CWI was non-inferior to TEA in terms of mean pain scores at rest (mean difference −0.13, 95% c.i. −0.72 to 0.47). Additionally, CWI demonstrated superior pain relief at rest and higher-quality recovery scores on POD 3. Compared with CWI, TEA was associated with significantly decreased total opioid consumption and shortened time to the first passage of flatus, but a higher incidence of postoperative hypotension. No other outcome measures showed significant differences between the two groups. Conclusion: CWI was non-inferior to TEA during the early postoperative period, and has emerged as a favourable alternative to TEA, offering better pain relief and enhanced recovery on POD 3. Registration number: NCT04375826 (http://www.clinicaltrials.gov).

Yun WG, et al. J Gastric Cancer. 2021 Jun;21(2):169-178. https://doi.org/10.5230/jgc.2021.21.e15

Background: Pancreatic cancer is a highly aggressive malignancy with a poor prognosis. Neoadjuvant chemotherapy (NAC) is increasingly used to improve survival in patients with pancreatic cancer; however, it often results in nutritional deterioration, which may negatively impact patient outcomes. Therefore, this study aimed to assess the effect of changes in nutritional status on the long-term outcomes of patients with pancreatic cancer who underwent curative surgery after NAC. Methods: This retrospective single-center study included 148 patients with pancreatic cancer who underwent curative surgery after NAC between 2010 and 2020. The Controlled Nutritional Status (CONUT) score was used to determine the nutritional status of the patients. Patients were categorized into worsened, maintained, and improved groups based on the changes in their CONUT scores before and after NAC. We compared differences in overall survival (OS) and disease-free survival (DFS) between the groups. Results: The worsened nutritional status group exhibited the shortest median OS (28 months) compared to the maintained and improved groups (39 and 66 months, respectively; p = 0.01). Additionally, the worsened group demonstrated the shortest DFS compared to the other two groups (13, 22, and 39 months, respectively; p = 0.02). Multivariate analysis identified nutritional deterioration as an independent prognostic factor for OS (hazard ratios (HR), 2.11; 95% confidence intervals (CI), 1.31–3.40; p < 0.01). Conclusions: Nutritional deterioration after NAC is a significant prognostic factor of poor survival outcomes in patients with pancreatic cancer. These findings indicate that serial nutritional assessments and treatment during NAC are crucial for improving patient outcomes.

Background: R0 rates have increased as neoadjuvant treatment (NAT) has become the primary treatment for pancreatic ductal adenocarcinoma (PDAC) with venous involvement, suggesting a decrease in venous tumor infiltration. The aim of this study was to investigate the clinical outcomes of preserving the portal/superior mesenteric vein (PV/SMV) during pancreaticoduodenectomy (PD) in PDAC patients who underwent NAT. Material and methods: The 113 patients with resectable and borderline resectable PDAC with venous involvement who responded to NAT and underwent curative PD between 2012 and 2022 were retrospectively reviewed. Results: Among the 113 patients, PV/SMV preservation (PVP) was performed in 68 patients (60.2%), and PV/SMV resection (PVR) was performed in 45 patients (39.8%). There was no significant difference in the R0 rate, 5-year overall survival (OS) and recurrence-free survival between the two groups. PV/SMV stenosis within 3 months after surgery was more common in the PVR group than in the PVP group (1.5% versus 22.2%; P<0.001), and 5-year PV/SMV stenosis-free survival was significantly higher in the PVP group than in the PVR group (76.5% versus 53.4%; P=0.014). Multivariate analysis showed that gemcitabine-based neoadjuvant chemotherapy was associated with poor OS. PVR, clinically relevant postoperative pancreatic fistula, and locoregional recurrence were independent risk factors for PV/SMV stenosis. Conclusion: The PVP group had similar oncologic outcomes and better vessel-functional outcomes than the PVR group. Therefore, if dissection is possible and there is a high likelihood of achieving R0 resection after NAT, routine PVR may be unnecessary in PDAC patients with venous involvement.