Table 1.
REDISCOVER recommendations (from Ann Surg. 2024 Feb 26. 10.1097/SLA.0000000000006248)
| Recommendations | LoE | SoR | Expert agreement% | Audience agreement% | Quality score% | ||
|---|---|---|---|---|---|---|---|
| 1 | Centralization | There are no specific criteria to identify institutions for the centralization of BR and LA-PDAC, however, there is good evidence to support volume–outcome interaction in pancreatic surgery. Patients requiring pancreatectomy with vascular resection should be centralized to centers of excellence with specific experience in these procedures. Patients should be enrolled in prospective database and/or registries | Low | Expert opinion | 96 | 93 | 73 |
| 2 | Vascular resection | Vascular resection and reconstruction is a component of contemporary pancreatic surgery. Pancreatic surgeons should achieve proficiency in vascular resection and reconstruction | Low | Expert opinion | 95 | 97 | 73 |
| 3 | Staging of BR- and LA-PDAC | The clinical staging of patients with BR and LA PDAC should include pancreas protocol CT/MRI in addition to CT of the chest and baseline Ca19.9 | Low | Expert opinion | 92 | 94 | 69 |
| 4 | Ca 19.9 non-secretors | In these patients baseline CEA and Ca 125 may be useful | Moderate | Weak | 93 | 94 | 67 |
| 5 | FDG-PET for BR- and LA-PDAC | There is no specific role for routine FDG-PET in BR- and LA-PDAC. However, FDG-PET can be selectively employed in patients at higher risk of occult metastasis and to permit evaluation of metabolic response following preoperative oncology treatments | Low | Weak | 97 | 97 | 76 |
| 6 | Endoscopic ultrasonography without biopsy | While most patients with BR- and LA-PDAC undergo preoperative EUS to achieve tissue cytology/histology, there is no evidence that EUS should be performed only for staging purposes | Low | Expert opinion | 91 | 99 | 76 |
| 7 | Pretreatment biopsy | Tissue diagnosis should be obtained in patients with BR- and LA-PDAC before preoperative oncology treatments. Inordinate delay of treatment should be avoided | Low | Expert opinion | 96 | 99 | 74 |
| 8 | Baseline staging laparoscopy | Baseline staging laparoscopy is not advised as a routine. Staging laparoscopy can detect occult metastases in selected patients | Low | Expert opinion | 96 | 97 | 73 |
| 9 | Timing of surgery after neoadjuvant treatments | There is no evidence about the optimal timing for surgical resection in patients with BR- or LA-PDAC following neoadjuvant chemo ± radiation therapy. Following NCCN guidelines which indicate that surgery should be performed 4 to 8 weeks after completion of chemotherapy is recommended. All patients should have their case discussed at multidisciplinary tumor board | Low | Expert opinion | 98 | 97 | 74 |
| 10 | Delaying surgery (“test of time”) | There is insufficient evidence to recommend waiting longer than 6 weeks after the end of neoadjuvant chemotherapy. Multidisciplinary tumor board discussion should recommend the best timing for surgical resection in individual patients | Low | Expert opinion | 99 | 94 | 62 |
| 11 | Molecular biomarkers in patient selection for surgery | There is currently no evidence of benefit from molecular biomarkers in patient selection for surgery. However genetic testing for inherited mutations and molecular tumor profiling is advised | Low | Weak | 99 | 98 | 69 |
| 12 | Staging laparoscopy after neoadjuvant treatments (BR-PDAC) | In patients with BR-PDAC, staging laparoscopy may be recommended prior to pancreatic resection if there is suspicion of occult metastases or unresectability | Low | Weak | 91 | 96 | 76 |
| 13 | Staging laparoscopy after neoadjuvant treatments (LA-PDAC) | In patients with LA-PDAC, staging laparoscopy is advised prior to laparotomy | Low | Weak | 91 | 90 | 75 |
| 14 | Intraoperative ultrasounds | The assessment of resectability of BR-PDAC and LA-PDAC resectability following neoadjuvant therapies does not specifically call for the routine use of intraoperative ultrasound. Intraoperative ultrasound can be used to define anatomy | Low | Expert opinion | 97 | 94 | 69 |
| 15 | Pancreatic resection after neoadjuvant treatment (BR-PDAC) | In patients fit for surgery with BR-PDAC, surgical resection improves survival | Moderate | Strong* | 93 | 87 | 72 |
| 16 | Pancreatic resection after neoadjuvant treatment (LA-PDAC) | In the absence of progression with good biological response complete surgical resection should be considered to improve survival. All patients should be discussed at a multidisciplinary tumor board. Only centers of excellence should perform these surgeries | Low | Weak | 84 | 82 | 74 |
| 17 | Pancreatic resection without neoadjuvant treatment (BR-PDAC) | In patients fit for surgery with BR-PDAC who, for any reason, cannot receive neoadjuvant multi-agent chemotherapy, surgery may improve survival. Neoadjuvant chemoradiotherapy could be taken into consideration as an alternative to upfront surgery. All patients should be discussed at multidisciplinary tumor board. Only centers of excellence should perform these surgeries | Low | Weak | 88 | 81 | 67 |
| 18 | Pancreatic resection after neoadjuvant treatments and rising Ca 19.9 levels (BR-PDAC) | Rising Ca19.9 is considered a significant adverse prognostic factor for early recurrence after resection. All patients should be discussed at multidisciplinary tumor board. Only centers of excellence should perform these surgeries | Low | Expert opinion | 97 | 89 | 76 |
| 19 | Pancreatic resection after neoadjuvant treatments and oligometastic disease (BR-PDAC) |
(a) Oligometastatic disease that develops during neoadjuvant therapy should be considered progression of disease and surgery should not be performed (b) Patients with synchronous oligometastatic disease who receive neoadjuvant therapy and show a good response may be considered for surgical resection in very selected cases and after discussing with patient and family. All patients should be discussed at multidisciplinary tumor board. Only centers of excellence should perform these surgeries |
Low | Expert opinion | 91 | 92 | 69 |
| 20 | Neoadjuvant chemo-radiation and postoperative complications | There is no evidence that chemo-radiation increases incidence and severity of postoperative complications compared to chemotherapy alone in patients with BR-PDAC undergoing pancreatic resection | Low | Weak | 96 | 95 | 80 |
| 21 | Epidural anesthesia/analgesia | Epidural anesthesia can be used. There is no evidence of superiority over standard anesthesia/analgesia | High | Strong | 96 | 93 | 69 |
| 22 | En bloc resection of tumor and involved vessels | Attempting en-bloc resection is an established oncologic principle and should be followed | Low | Expert opinion | 92 | 91 | 63 |
| 23 | Grafts/patches for vascular reconstruction | Autologous grafts (either vessels or peritoneum), allografts (usually vessels), xenografts (usually bovine pericardium), and prosthetic grafts can all be used for vascular reconstruction at the time of pancreatectomy depending on availability, type of reconstruction, and surgeon preference | Moderate | Weak | 97 | 99 | 68 |
| 24 | Frozen section of periarterial tissues | There is insufficient evidence to define the value of frozen section histology of periarterial tissues when discriminating between cancer invasion and perivascular fibrosis. Positive frozen section histology can be employed to decide to proceed with vascular resection or to abort the procedure | Low | Weak | 98 | 96 | 71 |
| 25 | Arterial divestment | In BR-PDAC and LA-PDAC, there is no clear proof that arterial divestment increases R1 rates when compared to arterial resection | Low | Expert opinion | 96 | 93 | 62 |
| 26 | Lymphadenectomy | There is no evidence to support what an optimal lymphadenectomy is in BR-PDAC and LA-PDAC | Low | Expert opinion | 95 | 97 | 64 |
| 27 | Hepatic artery embolization in DPCAR | Embolization of the common hepatic artery, in preparation for distal pancreatectomy with en-bloc resection of the celiac trunk, does not completely prevent hepatic and/or gastric ischemia | High | Strong | 93 | 90 | 69 |
| 28 | Hepatic artery reconstruction in DPCAR | The hepatic artery should be reconstructed when there are concerns of developing hepatic ischemia. However there is minimal evidence to define when the common hepatic artery should be reconstructed in a distal pancreatectomy with en-bloc resection of the celiac trunk | Low | Expert opinion | 93 | 90 | 69 |
| 29 | Gastric ischemia in DPCAR | In patients requiring total pancreatectomy with en-bloc resection of the celiac trunk gastric ischemia cannot be prevented in all patients. Surgeons should also be aware of venous congestion. If blood supply to the stomach appears sub-optimal, a low threshold to either partial or total gastrectomy should be adopted | Low | Expert opinion | 96 | 95 | 60 |
| 30 | Total pancreatectomy and artery resection | Total pancreatectomy is an option in selected patients, particularly when the risk of of pancreatic fistula is felt to be high. Surgeons performing arterial resection should register outcomes into prospective database and/or registries | Low | Expert opinion | 95 | 90 | 69 |
| 31 | Minimally invasive surgery in BR-PDAC | There is a role for minimally invasive pancreas resection in BR-PDAC. Further experience should continue in centers of excellence, meeting the criteria established by Miami and Brescia guidelines. Patients should be enrolled in prospective database and/or registries | Low | Expert opinion | 96 | 83 | 62 |
| 32 | Minimally invasive surgery in LA-PDAC | There is a very limited role for minimally invasive pancreas resection in LA-PDAC. Further experience should continue in centers of excellence, meeting the criteria established by Miami and Brescia guidelines. Patients should be enrolled in prospective database and/or registries | Low | Expert opinion | 92 | 80 | 58 |
| 33 | Anticoagulation in vein resection | Data about anticoagulation management after pancreatectomy with vein resection and reconstruction are inconclusive | Low | Expert opinion | 99 | 100 | 64 |
| 34 | Anticoagulation in artery resection | Data about anticoagulation management after pancreatectomy with artery resection and reconstruction are sparse and inconclusive | Low | Expert opinion | 97 | 100 | 65 |
LoE Level of evidence, SoR strength of recommendation, DPCAR distal pancreatectomy with resection of the celiac artery
*Upgraded by experts