The Dutch pancreatic cancer project: Improving outcome in pancreatic surgery

Pancreatic surgery is complex and carries a high risk of complications. This thesis entitled “The Dutch Pancreatic Cancer Project: improving outcome in pancreatic surgery”, aims to identify factors adding to the improvement of clinical outcome of patients after pancreatic surgery, first by focusing on the reduction of complications (Part I) and secondly by identifying leads to improve survival (Part II). In part I of this thesis, the leakage of pancreatic fluid after pancreatic surgery, i.e. postoperative pancreatic fistula (POPF, i.e. grade B/C), was addressed as the most feared complication in pancreatic surgery. Furthermore, the need for preventive measures was emphasized. In pancreatic cancer patients who received preoperative chemoradiotherapy, the rate of POPF was significantly lower compared to patients after immediate surgery (i.e., without preoperative therapy) after pancreatoduodenectomy. Changes in acinar cell function and pancreatic texture caused by radiotherapy may play a role in this declined risk of POPF. However, preoperative chemoradiotherapy is only indicated for patients undergoing PD for patients with pancreatic cancer, while this thesis concluded that patients with periampullary tumors have a much higher risk of developing POPF. It was hypothesized that a single dose of preoperative radiotherapy targeting the intended site of the pancreatic anastomosis induces local fibrosis of the pancreatic tissue, potentially reducing the risk of pancreatic fistula after pancreatoduodenectomy in patients at high risk of POPF. The FIBROPANC study protocol was presented, in which the safety and feasibility of this hypothesis will be investigated. Additionally, it was concluded that several national efforts have resulted in a significant decrease in in-hospital mortality and an improvement in failure to rescue after pancreatoduodenectomy in the Netherlands. In part II of this thesis, a unified variable list for reporting patient characteristics and outcome measures in randomized trials in patients with pancreatic cancer was presented, enabling better comparison between trials. It was also concluded that the basal-like molecular subtype of pancreatic carcinoma is associated with poor survival after pancreatic resection. In addition, involvement of the para-aortic lymph node station 16b1 is also associated with poor survival in patients with pancreatic or periampullary carcinoma. The role of direct resection in these groups was discussed