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Background: It is not clear whether resection of the primary tumour (when there are metastases) alters survival and/or whether resection is associated with increased morbidity. This systematic review and meta‐analysis assessed the prognostic value of primary tumour resection in patients presenting with metastatic colorectal cancer. Methods: A systematic review of MEDLINE/PubMed was performed on 12 March 2016, with no language or date restrictions, for studies comparing primary tumour resection versus conservative treatment without primary tumour resection for metastatic colorectal cancer. The quality of the studies was assessed using the MINORS and STROBE criteria. Differences in survival, morbidity and mortality between groups were estimated using random‐effects meta‐analysis. Results: Of 37 412 initially screened articles, 56 retrospective studies with 148 151 patients met the inclusion criteria. Primary tumour resection led to an improvement in overall survival of 7·76 (95 per cent c.i. 5·96 to 9·56) months (risk ratio (RR) for overall survival 0·50, 95 per cent c.i. 0·47 to 0·53), but did not significantly reduce the risk of obstruction (RR 0·50, 95 per cent c.i. 0·16 to 1·53) or bleeding (RR 1·19, 0·48 to 2·97). Neither was the morbidity risk altered (RR 1·14, 0·77 to 1·68). Heterogeneity between the studies was high, with a calculated I2 of more than 50 per cent for most outcomes. Conclusion: Primary tumour resection may provide a modest survival advantage in patients presenting with metastatic colorectal cancer. [ABSTRACT FROM AUTHOR]

Background: Although some retrospective studies of extended radical lymphadenectomy for pancreatic cancer have suggested a survival advantage, this is controversial. Methods: A literature search identified randomized controlled trials comparing extended with standard lymphadenectomy in pancreatic cancer surgery. Overall survival was analysed using hazard ratios and standard errors. Pooled estimates of overall treatment effects were calculated using a random effects model (odds ratio and 95 per cent confidence interval). Results: Of four randomized trials identified for systematic review, three were included in a meta-analysis of survival. The log hazard ratios (standard errors) for survival for the three trials were 0.36 (0.22), -0.15 (0.17) and -0.21 (0.15); the weighted mean log hazard ratio for survival overall was 0.93 (95 per cent confidence interval 0.77 to 1.13), revealing no significant differences between the standard and extended procedure (P = 0.480). Morbidity and mortality rates were also comparable, with a trend towards higher rates of delayed gastric emptying for extended lymphadenectomy. The number of resected lymph nodes was significantly higher in the extended lymphadenectomy groups (P < 0.001). Conclusion: The extended procedure does not benefit overall survival, and there may even be a trend towards increased morbidity. Therefore extended lymphadenectomy should be performed only within adequately powered controlled trials, if at all. [ABSTRACT FROM AUTHOR]

Aims: To assess the roles of adjuvant chemotherapy and chemoradiation in resectable pancreatic cancer. Methods: ESPAC-1 is the largest randomized adjuvant pancreatic study aiming to answer two questions: (i) is there a role for chemoradiation (40Gy + 5-fluorouracil); (ii) is there a role for chemotherapy (5-fluorouracil + folinic acid). 541 patients with pancreatic ductal adenocarcinoma were randomized from 83 clinicians in 11 countries. Quality of life (QoL) was assessed by patient questionnaires (EORTC QLQ-C30/ESPAC-QLQ32) completed at 3-monthly intervals. Additional QoL-related information was collected by the clinician (performance status, weight, diabetes and enzyme supplements). Changes in dimension scores within 6 months from entry were compared between treatments. Calculation of the quality adjusted life months (QALM) for the global QoL score enabled the length of survival and QoL to be combined. Results: Two hundred and twenty-seven patients (42 per cent) are alive with median follow-up of 10 months (interquartile range 1–25). Preliminary results show no evidence of a survival benefit for chemoradiation treatment (median survival 15.5 months with chemoradiation versus 16.1 months without, P = 0.24). There is evidence of a benefit for patients having chemotherapy (median survival 19.7 months with chemotherapy versus 14.0 months without, P < 0.001). A total of 296 patients have completed 789 QoL questionnaires within 1 year of entry. Initial analysis suggests there is a slight detriment with chemotherapy for social functioning (P = 0.03), role functioning (P = 0.02) and constipation (P = 0.05), within the 6 months from entry. However, with adjustment for multiple comparisons these differences become non-significant (P > 0.05). There are no significant differences in the QALM between either treatment comparisons within the first 12 months from entry to trial (no chemotherapy versus chemotherapy, P = 0.37; no chemoradiation versus chemoradiatio... [ABSTRACT FROM AUTHOR]

Background: Postpancreatectomy haemorrhage (PPH) is a rare but potentially fatal complication after pancreatoduodenectomy. Preventive strategies are lacking with scarce data for support. The aim of this study was to investigate whether a prophylactic falciform ligament wrap around the hepatic and gastroduodenal artery can prevent PPH from these vessels., Methods: In a randomized, controlled, multicentre trial, patients who were scheduled for elective open partial pancreatoduodenectomy with pancreatojejunostomy between 5 November 2015 and 2 April 2020 were randomly allocated in a 1 : 1 ratio to undergo pancreatoduodenectomy with (intervention) or without (control) a falciform ligament wrap around the hepatic artery. The primary endpoint was the rate of clinically relevant PPH from the hepatic artery or gastroduodenal artery stump within 3 months after pancreatoduodenectomy. Secondary endpoints were the rates of associated postoperative complications, for example postoperative pancreatic fistula (POPF) and PPH., Results: Altogether, 445 patients were randomized with 222 and 223 in each group. Among the patients included in modified intention-to-treat analysis (207 in the intervention group and 210 in the control group), the primary endpoint was observed in six of 207 in the intervention group compared with 15 of 210 in the control group (2.9 versus 7.1 per cent respectively; odds ratio 0.39 (95 per cent c.i. 0.15 to 1.02); P = 0.071). Per protocol analysis showed a significant reduction in the intervention group (odds ratio 0.26 (95 per cent c.i. 0.09 to 0.80); P = 0.017). A soft pancreas texture (43 per cent) and the rate of a clinically relevant POPF were evenly (20 per cent) distributed between the groups. The rate of any clinically relevant PPH including the primary endpoint and other bleeding sites was not significantly different between intervention and control groups (9.7 versus 14.8 per cent respectively)., Conclusion: A falciform ligament wrap may reduce PPH from the hepatic artery or gastroduodenal artery stump and should be considered during pancreatoduodenectomy., Registration Number: NCT02588066 (http://www.clinicaltrials.gov)., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)