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Ann Surg Oncol. 2019 Mar;26(3):772-781. doi: 10.1245/s10434-018-07101-0. Epub 2019 Jan 4.

Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR): An International Multicenter Analysis.

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Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
Department of Surgery, University of Utrecht Medical Center, Utrecht, The Netherlands.
Department of Surgery, Pancreas Institute University of Verona, Verona, Italy.
Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany.
Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Saale, Germany.
Second Department of Surgery, Wakayama Medical University, Wakayama, Japan.
Department of Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France.
The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest, Romania.
Department of HPB and Transplant Services, National Health Service, Leeds, UK.
Department of HPB Surgery, Hôpital Beaujon, APHP, University Paris VII, Clichy, France.
Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Department of Surgery, Northshore University HealthSystem, Chicago, IL, USA.
Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.



Distal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes.


This multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000-2016) and three very-high-volume international centers in the United States and Japan (model validation 2004-2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival.


For 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2-11%) at 5 high-volume (≥ 1 DP-CAR/year) and 18% (95 CI, 9-30%) at 18 low-volume DP-CAR centers (P = 0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P = 0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19 months (95 CI, 15-25 months).


When performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor.

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