Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss

doi:10.4240/wjgs.v15.i8.1663

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Aug 27, 2023 (publication date) through Aug 26, 2024

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastrointest Surg. Aug 27, 2023; 15(8): 1663-1672
Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1663

Table 1 Demographics and preoperative characteristics of patients with adenocarcinoma of the pancreas undergoing a pancreaticoduodenectomy from 2015 to 2019, n (%)

Characteristic	Subcategory	Initial surgery	Neoadjuvant radiation	P value
Characteristic	Subcategory	n = 9988	n = 1470	P value
Age in yr	Less than 50	511 (5.1)	89 (6.1)
	50-59	1638 (16.4)	304 (20.7)
	60-69	3526 (35.3)	585 (39.8)	< 0.001^a
	70-79	3287 (32.9)	430 (29.3)
	80 and above	1026 (10.3)	62 (4.2)
Male		5340 (53.5)	743 (50.5)	0.036^a
Race	White	7392 (81.6)	1203 (84.3)
	Black/African American	748 (8.3)	127 (8.9)
	Hispanic	462 (5.1)	54 (3.8)	< 0.001^a
	Asian	427 (4.7)	38 (2.7)
	Other	33 (0.4)	5 (0.4)
	Not reported	926	43
BMI	Normal	3683 (36.9)	618 (42.0)
	Underweight	244 (2.4)	37 (2.5)
	Overweight	3591 (36)	505 (34.4)	0.002^a
	Obese	1614 (16.2)	203 (13.8)
	Morbidly obese	856 (8.6)	107 (7.3)
Diabetes		2859 (28.6)	461 (31.4)	0.031^a
Smoking		1650 (16.5)	238 (16.2)	0.751
COPD		394 (3.9)	42 (2.9)	0.042^a
Dyspnea		507 (5.1)	57 (3.9)	0.047^a
HTN		5418 (54.2)	693 (47.1)	< 0.001^a
Preoperative steroid use		239 (2.4)	42 (2.9)	0.283
Jaundice		5759 (58.0)	431 (29.7)	< 0.001^a
Biliary stent		6457 (64.7)	979 (66.6)	0.235
Albumin, mean ± SD		3.69 (0.60)	3.85 (0.50)	< 0.001^a

^aP < 0.05.

BMI: Body mass index; COPD: Chronic obstructive pulmonary disease; HTN: Hypertension; SD: Standard deviation.

Table 2 Operative characteristics of patients with adenocarcinoma of the pancreas undergoing a pancreaticoduodenectomy from 2015 to 2019, n (%)

Characteristic	Subcategory	Initial surgery	Neoadjuvant radiation	P value
Characteristic	Subcategory	n = 9988	n = 1470	P value
Elective surgery		8921 (89.4)	1423 (96.8)	< 0.001^a
T-stage	T0/T1	2969 (29.7)	867 (59.0)
	T2	6133 (61.4)	544 (37.0)	< 0.001^a
	T3/T4	666 (6.7)	32 (2.2)
	Tis/unknown	128 (1.3)	39 (2.7)
N-stage	N0	2969 (29.7)	867 (59.0)
	N1	6133 (61.4)	544 (37.0)	< 0.001^a
	N2	666 (6.7)	32 (2.18)
M-stage	M0	7260 (72.7)	1109 (75.4)
	M1	172 (1.7)	20 (1.4)	0.073
	Unknown	2556 (25.6)	341 (23.2)
Wound class	Clean	242 (2.4)	33 (2.2)
	Clean-contaminated	7915 (79.3)	1142 (77.7)	0.034^a
	Contaminated	1547 (15.5)	233 (15.9)
	Dirty	284 (2.8)	62 (4.2)
Pancreatic duct size	< 3 mm	1987 (24.9)	304 (26.3)
	3-6 mm	4527 (56.8)	685 (59.2)
	> 6 mm	1461 (18.3)	168 (14.5)	0.007^a
	Unknown	2013	315
Resection of artery or vein		2217 (22.4)	554 (37.9)	< 0.001^a
Surgery approach	Open	9112 (91.2)	1386 (94.4)	< 0.001^a
	Robotic/laparoscopic	875 (8.8)	83 (5.7)

^aP < 0.05.

Table 3 Thirty-day postoperative complications for patients with adenocarcinoma of the pancreas undergoing a pancreaticoduodenectomy from 2015 to 2019, n (%)

Complication	Initial surgery	Neoadjuvant radiation	P value
Complication	n = 9988	n = 1470	P value
Wound dehiscence	110 (1.1)	16 (1.1)	0.965
Ventilator dependent > 48 h	223 (2.2)	38 (2.6)	0.398
Stroke	29 (0.3)	3 (0.2)	0.791
Myocardial infarction	124 (1.2)	9 (0.6)	0.035^a
DVT	269 (2.7)	55 (3.7)	0.024^a
Pulmonary embolism	108 (1.1)	5 (0.3)	0.004^a
Pneumonia	305 (3.1)	30 (2.0)	0.031^a
UTI	247 (2.5)	32 (2.2)	0.491
Septic shock	207 (2.1)	34 (2.3)	0.545

^aP < 0.05.

DVT: Deep venous thrombosis; UTI: Urinary tract infection.

Table 4 Odds ratios for 30-day postoperative complications for patients with adenocarcinoma of the pancreas undergoing a pancreaticoduodenectomy from 2015 to 2019

Complication	Neoadjuvant radiotherapy crude OR (95%CI)	Crude P value	Neoadjuvant radiotherapy adjusted OR/IRR (95%CI)	Adjusted P value
Total operative time	0.15 (0.13, 0.16)	< 0.001^a	1.14 (1.11,1.16)¹	< 0.001^a
Perioperative transfusion	1.49 (1.32, 1.69)	< 0.001^a	1.58 (1.37, 1.82)²	< 0.001^a
Superficial SSI	1.13 (0.93, 1.38)	0.217	NP	NP
Organ space SSI	0.76 (0.63, 0.91)	0.004^a	0.80 (0.66, 0.97)³	0.020^a
30-d reoperation	1.03 (0.80, 1.32)	0.832	NP	NP
30-d mortality rate	0.40 (0.21, 0.75)	0.005^a	NP	NP
30-d readmission rate	1.14 (0.98, 1.32)	0.090	NP	NP
Renal failure	0.74 (0.37, 1.47)	0.382	NP	NP
Total hospital stay	0.09 (0.06, 0.12)	< 0.001^a	0.99 (0.96, 1.02)⁴	0.640
Drain in place on POD 30	0.76 (0.61, 0.99)	0.041^a	0.82 (0.64, 1.06)⁵	0.124
Pancreatic fistula	0.47 (0.38, 0.58)	< 0.001^a	0.50 (0.40, 0.63)⁵	< 0.001^a
Delayed gastric emptying	0.81 (0.69, 0.95)	0.010^a	0.86 (0.72, 1.01)⁵	0.073

^aP < 0.05.

¹Odds ratio was adjusted for: Albumin, age, sex, race, body mass index (BMI), diabetes, dyspnea, chronic obstructive pulmonary disease (COPD), hypertension, elective surgery, wound class, biliary stent, pancreatic duct size, perioperative transfusion requirement, surgical approach, resection of artery or vein.

²Odds ratio was adjusted for: Albumin, age, sex, race, BMI, diabetes, dyspnea, COPD, hypertension, elective surgery, wound class, biliary stent, surgical approach, resection of artery or vein, T-stage, N-stage.

³Odds ratio was adjusted for: Age, race, BMI, diabetes, steroids, wound class, American society of anesthesiologists (ASA) class, surgical approach, resection of artery or vein.

⁴Odds ratio was adjusted for: Age, race, BMI, diabetes, steroids, wound class, ASA class, surgical approach, resection of artery or vein, organ space infection, failure to wean off ventilator by post-operative day (POD) 30, drain in place by POD 30, return to the odds ratio within 30 d of index operation, delayed gastric emptying, T-stage, N-stage, M-stage.

⁵Odds ratio was adjusted for: Age, race, BMI, diabetes, steroids, wound class, ASA class, surgical approach, resection of artery or vein.

IRR: Insulin receptor-related receptor; NP: Not performed; OR: Odds ratio; POD: Post-operative day; SSI: Surgical site infection.

Citation: Aploks K, Kim M, Stroever S, Ostapenko A, Sim YB, Sooriyakumar A, Rahimi-Ardabily A, Seshadri R, Dong XD. Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss. World J Gastrointest Surg 2023; 15(8): 1663-1672
URL: https://www.wjgnet.com/1948-9366/full/v15/i8/1663.htm
DOI: https://dx.doi.org/10.4240/wjgs.v15.i8.1663