Predictors of intraoperative resectability among pancreatic cancer patients for curative-intent surgery: a systematic review with meta-analysis

BackgroundSome pancreatic cancer patients for curative-intent surgery are found to actually have unresectable disease on laparotomy. This systematic review aimed to identify parameters that can potentially help predict intraoperative resectability status. MethodsLiterature search was done across PubMed, Scopus, Web of Science, and Cochrane Library to identify studies since 2011 assessing for independent association of preoperative parameters with intraoperative pancreatic cancer resectability. Parameters investigated by at least two studies were identified. For discordant findings, meta-analyses using the random effects model were done, incorporating studies that can be pooled. Pooled odds ratios and mean differences were obtained for parameters with binary and continuous values, respectively, with 95% confidence intervals. Subgroup analyses were done for significant heterogeneity. ResultsFrom initially 8,959 articles searched, 18 studies were included, with 13 parameters identified for synthesis. Elevated serum CA19-9 (>35-1000 U/mL) and larger tumor size (>22-40 mm) were shown to independently predict intraoperative unresectability in the most number of studies. For parameters subjected to meta-analyses, abdominal pain, weight loss, lower body mass index (BMI), lower serum transaminases, and preoperative borderline resectability were significantly associated with intraoperative unresectability, while age and sex were not. Subgroup analyses addressing heterogeneity revealed that tumor location in the pancreatic body/tail is significantly associated with actual unresectability whereas poorer performance status was not. Other parameters shown to have predictive value but could not be included in meta-analyses are serum CA125 and imaging-to-surgery time interval. ConclusionSynthesis of studies has shown that elevated serum CA19-9 and larger tumors are independently associated with intraoperative pancreatic cancer unresectability. Other predictive factors include abdominal pain, weight loss, lower BMI, lower serum transaminases, preoperative borderline resectability, and tumor location in the pancreatic body/tail. Staging laparoscopy or neoadjuvant therapy should be considered for potentially resectable pancreatic cancer patients with these attributes. What is already known on this topicAccurate identification of patients with actual resectable pancreatic cancer remains challenging despite resectability criteria. Some parameters beyond resectability criteria have been found to offer clues regarding actual resectability. What this study addsSynthesis of studies has determined which clinical, laboratory, and radiologic parameters outside of resectability criteria may predict intraoperative resectability among pancreatic cancer patients being considered for curative-intent surgery. How this study might affect research, practice, or policyThe findings in this study may aid in deciding which pancreatic cancer patients should undergo staging laparoscopy first instead of directly attempting curative surgery. Research gaps have also been identified.