Published online Oct 24, 2026. doi: 10.5306/wjco.124078
Revised: August 5, 2026
Accepted: October 9, 2026
Published online: October 24, 2026
Processing time: 139 Days and 9.2 Hours
Pancreatic neck cancer occurs in a unique anatomic location. The optimal radical surgical approach among distal pancreatectomy (DP), pancreaticoduodenectomy (PD), and total pancreatectomy (TP) remains controversial, especially in patients without gastroduodenal artery (GDA) invasion.
To evaluate how different surgical procedures affect overall survival (OS) and disease-free survival (DFS) in pancreatic neck cancer patients without preoperative radiographic evidence of GDA invasion.
This single-center retrospective cohort study included 174 consecutive patients with pancreatic neck cancer who underwent radical resection with curative intent at Fudan University Shanghai Cancer Center between January 2017 and January 2022. None of the patients showed preoperative radiographic signs of GDA inva
The cohort comprised 107 patients (61.5%) in the DP group, 41 (23.6%) in the PD group, and 26 (14.9%) in the TP group. The median OS for the entire cohort was 27.3 months, and median DFS was 17.5 months. On univariate analysis, TP was associated with significantly worse survival compared to PD and DP (OS: 17.7 vs 35.1 vs 32.2 months, P = 0.014; DFS: 11.9 months vs 19.2 months vs 20.3 months, P = 0.017). Cox multivariate analysis identified T stage [hazard ratio (HR) = 1.840, 95%CI: 1.166-2.905], tumor differentiation grade (HR = 0.311, 95%CI: 0.109-0.888), and R1 resection (HR = 2.226, 95%CI: 1.258-3.938) as independent prognostic factors for OS. After adjusting for these confounders, the type of surgical procedure was not significantly associated with OS or DFS
Surgical approach is not an independent prognostic determinant in pancreatic neck cancer patients. When R0 clearance can be achieved by DP, extending resection to PD or TP does not appear to confer a survival advantage.
Core Tip: This retrospective cohort study of 174 patients with pancreatic neck cancer without gastroduodenal artery invasion compared distal pancreatectomy (DP), pancreaticoduodenectomy (PD), and total pancreatectomy (TP). After multivariable adjustment, surgical procedure was not an independent predictor of overall or disease-free survival; T stage, tumor differentiation, and R1 resection were. When R0 clearance can be achieved by DP, extending resection to PD or TP does not appear to improve survival.
- Citation: Ma MJ, Cheng H, Chen YS, Yu XJ, Liu C. Impact of different surgical approaches on prognosis in patients with pancreatic neck cancer: A retrospective cohort study. World J Clin Oncol 2026; 17(10): 124078
- URL: https://www.wjgnet.com/2218-4333/full/v17/i10/124078.htm
- DOI: https://dx.doi.org/10.5306/wjco.124078
Pancreatic cancer (PC) remains a highly lethal malignancy, with a 5-year overall survival (OS) rate below 10% despite advances in systemic therapy and surgical safety[1,2]. Radical resection offers the only potential for cure, yet only 15%-20% of patients present with surgically resectable disease at initial diagnosis[3]. Pancreatic neck cancer accounts for less than 20% of all PC cases[4-6]. Due to its unique anatomic location-posteriorly adjacent to the portal vein (PV)/superior mesenteric vein (SMV) system, superiorly close to the common hepatic artery, leftward of the celiac axis, and rightward of the gastroduodenal artery (GDA)-these tumors often exhibit vascular invasion even when small[5].
The National Comprehensive Cancer Network guidelines recommend pancreaticoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) for pancreatic neck cancer, with R0 resection being the primary objective. For pancreatic neck cancer without GDA involvement, R0 resection can be achieved through PD, DP, or TP; however, there is currently no consensus on which surgical approach offers the greatest long-term survival benefit[7,8]. Therefore, we conducted this retrospective clinical study to evaluate the optimal surgical strategy for pancreatic neck cancer without preoperative radiological evidence of GDA invasion, aiming to provide a theoretical foundation for clinical decision-making.
We retrospectively analyzed patients undergoing radical resection for pathologically confirmed pancreatic neck cancer at Fudan University Shanghai Cancer Center between January 1, 2017, and January 1, 2022. Pancreatic neck cancer was defined as a malignancy located to the left of the GDA, anterior to the PV/SMV, and inferior to the hepatic artery on preoperative imaging and intraoperative assessment[5]. Exclusion criteria included: (1) Distant metastasis at diagnosis; (2) Preoperative imaging suggesting GDA invasion; (3) Preoperative imaging suggesting common bile duct invasion; (4) Final pathology indicating benign disease; or (5) A history of another active malignancy.
Although our inclusion criteria were restricted to patients without radiographic involvement of the GDA-a cohort in whom R0 resection could theoretically be achieved by any of the three procedures=the final surgical approach (TP, PD, or DP) was ultimately selected intraoperatively based on tumor extent and surgeon assessment. For cases with PV/SMV involvement, regardless of the chosen procedure, an “en-bloc” resection strategy adhering to the “leave the vein alone” principle was employed[9].
The patient was placed in a supine position with legs apart. An exploratory laparotomy was performed first to rule out metastases. The gastrocolic ligament was opened, and the SMV was exposed by dissecting along the inferior margin of the pancreas. A Kocher maneuver was performed to mobilize the descending and horizontal parts of the duodenum and the retropancreatic tissue behind the pancreatic head. After assessing local tumor resectability, we performed a cho
During dissection of the hepatoduodenal ligament, the common bile duct was divided and the common hepatic artery was suspended, allowing for clear exposure of the PV. A retropancreatic tunnel was created behind the pancreatic neck, which was then transected. After dividing the jejunum and partial duodenal mesenteries, the jejunum was transected approximately 15 cm from the ligament of Treitz. The proximal jejunal limb was retracted to the right side, and the mesentery of the uncinate process was dissected and divided close to the right side of the SMV/PV. The arterial branches from the superior mesenteric artery (SMA) to the uncinate process and the tributaries from the uncinate process to the SMV/PV were clipped and divided. The uncinate process was completely resected along the right side of the SMV. After specimen removal, reconstruction was performed sequentially according to the classic Child’s procedure, including pancreaticojejunostomy, cholangiojejunostomy, and gastrojejunostomy. Abdominal drainage tubes were routinely placed above the pancreaticojejunostomy, below the cholangiojejunostomy, and in the right retroperitoneal region.
Upon confirmation of no metastatic disease, the gastrocolic ligament was divided to expose the pancreas. Dissection proceeded along the pancreatic borders, identifying the hepatic artery, PV, left gastric vessels, and splenic artery superiorly, as well as the SMV inferiorly. A tunnel was created posterior to the pancreatic neck. The neck was transected to the left of the GDA, and the pancreatic stump was closed and reinforced. Following transection, the splenic artery and vein were ligated and divided. The pancreatic body/tail and spleen were mobilized by dividing the retroperitoneal atta
After confirming the absence of metastasis, a Harmonic scalpel was used to open the gastrocolic ligament. Dissection was then performed along the inferior border of the pancreas to expose the SMV. Further dissection proceeded anterior to the PV, extending from the inferior to the superior border of the pancreas, to establish a retropancreatic tunnel. The lesser sac was opened, and the stomach was transected distal to the pylorus. The common hepatic artery, PV, and bile duct were dissected within the hepatoduodenal ligament. The GDA was ligated at its origin. Following a cholecystectomy, the splenic vessels were ligated proximally and divided. The pancreatic body/tail and spleen were then mobilized in the same manner as described for DP. The jejunum was transected ~10 cm distal to the ligament of Treitz. A Kocher ma
OS was defined as the time from surgery to death from any cause or last follow-up. Disease-free survival (DFS) was defined as the time from surgery to radiological/pathological confirmation of recurrence or last follow-up. Continuous variables with a normal distribution were expressed as mean ± SD, whereas those with a skewed distribution were presented as median (range). Categorical variables were summarized as counts and percentages, expressed as n (%). Continuous variables were compared using Student’s t-test or the Mann–Whitney U test for two-group comparisons, and one-way analysis of variance or the Kruskal-Wallis test for three-group comparisons, as appropriate. Categorical varia
Survival probabilities were estimated by the Kaplan–Meier method, with intergroup differences assessed using the log-rank test. Variables with P < 0.1 in univariate analysis were entered into a Cox proportional hazards regression model for multivariate analysis. The proportional hazards assumption was evaluated using Schoenfeld residuals; variables violating this assumption were addressed using stratified Cox models as sensitivity analyses. To minimize confounding by indica
The study included 174 pancreatic neck cancer patients: DP (n = 107, 61.5%), PD (n = 41, 23.6%), and TP (n = 26, 14.9%). There were no perioperative mortalities. Baseline characteristics are summarized in Table 1. The three groups were comparable regarding gender, age, body mass index, preoperative CA199, histopathological type, tumor grade, presence of intravascular cancer thrombus, nerve invasion, N stage, number of dissected lymph nodes, number of metastatic lymph nodes, lymph node ratio, neoadjuvant therapy, and R0 resection rate (P > 0.05). However, the TP group had signi
| Variable | Type of surgery | P value | ||
| DP (n = 107) | PD (n = 41) | TP (n = 26) | ||
| Gender | 0.101 | |||
| Male | 45 (42.1) | 20 (48.8) | 17 (65.4) | |
| Female | 62 (57.9) | 21 (51.2) | 9 (34.6) | |
| Age (years) | 65 (59-70) | 64 (59-69) | 65 (57-67) | 0.472 |
| BMI (kg/m2) | 22.93 ± 2.69 | 23.50 ± 3.14 | 22.75 ± 2.36 | 0.445 |
| CA19-9 (U/mL) | 0.889 | |||
| < 37 | 30 (28.0) | 13 (31.7) | 8 (30.8) | |
| ≥ 37 | 77 (72.0) | 28 (68.3) | 18 (69.2) | |
| Tumor size (cm) | 2.6 (2-3.2) | 2.5 (2-3) | 4 (3.225-4.5) | < 0.001 |
| Pathological type | 0.875 | |||
| PDAC | 97 (90.7) | 39 (95.1) | 24 (92.3) | |
| IPMN | 7 (6.5) | 2 (4.9) | 1 (3.8) | |
| Others | 3 (2.8) | 0 (0) | 1 (3.8) | |
| T stage | < 0.001 | |||
| T1-T2 | 72 (67.3) | 32 (78) | 9 (34.6) | |
| T3-T4 | 35 (32.7) | 9 (22) | 17 (65.4) | |
| N stage | 0.860 | |||
| N0 | 62 (57.9) | 25 (61.0) | 14 (53.8) | |
| N1-N2 | 45 (42.1) | 16 (39.0) | 12 (46.2) | |
| Grade | 0.436 | |||
| Poorly differentiated | 39 (36.4) | 13 (31.7) | 12 (46.2) | |
| Moderately differentiated | 58 (54.2) | 27 (65.9) | 13 (50.0) | |
| Well differentiated | 10 (9.3) | 1 (2.4) | 1 (3.8) | |
| Intravascular cancer thrombus | 36 (33.6) | 14 (34.1) | 9 (34.6) | 1.000 |
| Nerve invasion | 83 (77.6) | 35 (85.4) | 23 (88.5) | 0.382 |
| AJCC stage | 0.002 | |||
| I | 47 (43.9) | 20 (48.8) | 3 (11.5) | |
| IIA | 4 (3.7) | 0 (0) | 1 (3.8) | |
| IIB | 28 (26.2) | 12 (29.3) | 5 (19.2) | |
| III | 28 (26.2) | 9 (22) | 17 (65.4) | |
| Number of dissected lymph nodes | 16 (12-23) | 16 (11-22) | 22 (12.5-34.25) | 0.160 |
| Number of metastatic lymph nodes | 0 (0-1) | 0 (0-1) | 0 (0-2) | 0.745 |
| Lymph node ratio | 0 (0-8.33) | 0(0-7.69) | 0 (0-8.99) | 0.910 |
| Surgical margin | 0.852 | |||
| R0 | 94 (87.9) | 35 (85.4) | 22 (84.6) | |
| R1 | 13 (12.1) | 6 (14.6) | 4 (15.4) | |
| Operative time (minute) | 217.92 ± 68.75 | 296.37 ± 68.46 | 359.12 ± 74.79 | < 0.001 |
| Intraoperative blood loss (mL) | 200 (200-400) | 300 (200-500) | 650 (375-1725) | < 0.001 |
| Postoperative stay (days) | 12 (10-14) | 13 (11-14) | 14 (12-17) | 0.005 |
| Neoadjuvant therapy | 25 (23.4) | 11 (26.8) | 11 (42.3) | 0.157 |
| Adjuvant therapy | 90 (84.1) | 35 (85.4) | 15 (57.7) | 0.007 |
The median follow-up for the entire cohort was 46.1 months [interquartile range (IQR): 39.2–62.7], with 69 patients (39.7%) censored. Broken down by surgical approach, the median follow-up was 47.9 months (IQR: 40.5-64.5) for the DP group (43 censored 40.2%), 44.9 months (IQR: 38.3–59.8) for PD (21 censored 51.2%), and 39.6 months (IQR: 34.8-72.0) for the TP group (five censored 19.2%).
The median OS for the entire cohort was 27.3 months (Figure 1A) (DP: 32.2 months, PD: 35.1 months, TP: 17.7 months; log-rank P = 0.014; Figure 2A). The median DFS was 17.5 months (Figure 1B) (DP: 20.3 months, PD: 19.2 months, TP: 11.9 months; log-rank P = 0.017; Figure 2B).
The median OS was 23.3 months for lymph node–positive patients (N1/N2) vs 32.3 months for lymph node–negative patients (N0) (P = 0.094), while the median DFS was 12.7 months vs 21.4 months (P = 0.002). These results are presented in Figure 3A and 4A, respectively.
Among node-negative patients, striking differences in survival were observed across the surgical groups. The median OS was 48.9 months for the DP group, 81.6 months for the PD group, and 14.6 months for the TP group (P < 0.0001; Figure 3B). Similarly, median DFS differed significantly across these groups: 25.1 months (DP), 31.6 months (PD), and 11.4 months (TP) (P = 0.00019; Figure 3C).
In contrast, survival outcomes were comparable across surgical approaches for node-positive patients. The median OS was 25.3 months (DP), 23.3 months (PD), and 19.1 months (TP) (P = 0.87; Figure 4B). The median DFS also did not show a statistically significant difference: 12.9 months (DP), 11.5 months (PD), and 11.9 months (TP) (P = 0.89; Figure 4C).
Subgroup analysis stratified by pathologic stage revealed significant prognostic disparities. Patients with early-stage disease (stage I/IIA) demonstrated markedly longer survival outcomes compared to those with advanced-stage disease (stage IIB/III), with a median OS of 48.9 months vs 21.0 months (P = 0.00037; Figure 5A) and median DFS of 29.7 months vs 12.7 months (P < 0.0001; Figure 6A).
Within the early-stage subgroup, survival outcomes differed notably by surgical approach. While OS differences approached statistical significance (DP: 48.9 months, PD: 81.6 months, TP: 27.3 months; P = 0.059; Figure 5B), DFS varied significantly across groups (DP: 28.3 months, PD: 66.2 months, TP: 9.6 months; P = 0.038; Figure 5C).
Conversely, among advanced-stage patients, no significant survival differences were observed based on surgical pro
The results of the univariate and multivariate regression analyses for OS and DFS are presented in Tables 2 and 3, respectively. Multivariable analysis demonstrated that T stage (T3-T4 vs T1-T2), tumor differentiation (well vs poor), and surgical margin status (R1 vs R0) were independently associated with OS (P < 0.05). While surgical approach was not statistically significant, a trend favoring DP over TP was observed [hazard ratio (HR) = 1.632, 95%CI: 0.933-2.853; P = 0.086]. The wide CI may include a potential 2.8-fold increase in the hazard of death (Table 2).
| Variable | Univariate | Multivariate | ||
| HR (95%CI) | P value | HR (95%CI) | P value | |
| Gender | ||||
| Male | Reference | Reference | ||
| Female | 0.709 (0.481-1.044) | 0.082 | 0.758 (0.506-1.135) | 0.178 |
| Age (years) | 1.006 (0.982-1.031) | 0.629 | ||
| BMI (kg/m2) | 0.966 (0.898-1.039) | 0.348 | ||
| CA19-9 (U/mL) | ||||
| < 37 U/mL | Reference | |||
| ≥ 37 U/mL | 1.216 (0.784-1.887) | 0.382 | ||
| Grade | ||||
| Poorly differentiated | Reference | Reference | ||
| Moderately differentiated | 0.670 (0.451-0.995) | 0.047 | 0.746 (0.489-1.138) | 0.174 |
| Well differentiated | 0.312 (0.112-0.870) | 0.026 | 0.311 (0.109-0.888) | 0.029 |
| Intravascular cancer thrombus | ||||
| - | Reference | |||
| + | 1.076 (0.711-1.628) | 0.730 | ||
| Nerve invasion | ||||
| - | Reference | |||
| + | 1.457 (0.865-2.453) | 0.157 | ||
| T stage | ||||
| T1-T2 | Reference | Reference | ||
| T3-T4 | 2.267 (1.539-3.339) | < 0.001 | 1.840 (1.166-2.905) | 0.009 |
| N stage | ||||
| N0 | Reference | Reference | ||
| N1 + N2 | 1.387 (0.944-2.038) | 0.095 | 1.094 (0.736-1.626) | 0.656 |
| Surgical margin | ||||
| R0 | Reference | Reference | ||
| R1 | 3.044 (1.834-5.052) | < 0.001 | 2.226 (1.258-3.938) | 0.006 |
| Surgical procedure | ||||
| DP | Reference | Reference | ||
| PD | 0.772 (0.467-1.275) | 0.312 | 0.738 (0.442-1.233) | 0.246 |
| TP | 2.151 (1.309-3.536) | 0.003 | 1.632 (0.933-2.853) | 0.086 |
| Postoperative stay (days) | 1.002 (0.971-1.033) | 0.909 | ||
| Neoadjuvant therapy | ||||
| No | Reference | |||
| Yes | 0.962 (0.522-1.775) | 0.902 | ||
| Variable | Univariate | Multivariate | ||
| HR (95%CI) | P value | HR (95%CI) | P value | |
| Gender | ||||
| Male | Reference | |||
| Female | 0.796 (0.561-1.128) | 0.200 | ||
| Age (years) | 1.003 (0.982-1.024) | 0.781 | ||
| BMI (kg/m2) | 0.960 (0.897-1.027) | 0.238 | ||
| CA19-9 (U/mL) | ||||
| < 37 U/mL | Reference | |||
| ≥ 37 U/mL | 1.333 (0.896-1.985) | 0.157 | ||
| Grade | ||||
| Poorly differentiated | Reference | Reference | ||
| Moderately differentiated | 0.713 (0.495-1.028) | 0.070 | 0.752 (0.508-1.113) | 0.154 |
| Well differentiated | 0.451 (0.204-0.998) | 0.050 | 0.426 (0.186-0.973) | 0.043 |
| Intravascular cancer thrombus | ||||
| - | Reference | Reference | ||
| + | 1.565 (1.083-2.264) | 0.017 | 1.462 (0.956-2.236) | 0.079 |
| Nerve invasion | ||||
| - | Reference | Reference | ||
| + | 1.710 (1.048-2.789) | 0.032 | 1.116 (0.659-1.887) | 0.684 |
| T stage | ||||
| T1-T2 | Reference | Reference | ||
| T3-T4 | 2.004 (1.404-2.861) | < 0.001 | 1.761 (1.152-2.691) | 0.009 |
| N stage | ||||
| N0 | Reference | Reference | ||
| N1 + N2 | 1.722 (1.214-2.441) | 0.002 | 1.417 (0.963-2.084) | 0.077 |
| Surgical margin | ||||
| R0 | Reference | Reference | ||
| R1 | 3.021 (1.855-4.921) | < 0.001 | 2.312 (1.362-3.927) | 0.002 |
| Surgical procedure | ||||
| DP | Reference | Reference | ||
| PD | 0.831 (0.533-1.297) | 0.416 | 0.838 (0.532-1.320) | 0.446 |
| TP | 1.790 (1.119-2.862) | 0.015 | 1.258 (0.761-2.082) | 0.371 |
| Postoperative stay (days) | 1.001 (0.975-1.028) | 0.917 | ||
Regarding DFS (Table 3), after adjusting for covariates that were significantly associated with DFS on univariate ana
In the primary multivariable Cox model for OS, surgical margin status violated the proportional hazards assumption as assessed by scaled Schoenfeld residuals (Supplementary Table 1). Accordingly, a sensitivity analysis was performed using a Cox model stratified by margin status, which yielded results consistent with the primary model (Supplementary Table 2). The proportional hazards assumption was met for all variables in the primary multivariable Cox model for DFS, as assessed by scaled Schoenfeld residuals (Supplementary Table 3).
Furthermore, to minimize confounding by indication, we conducted an IPTW analysis using propensity scores derived from T stage. Supplementary Table 4 shows the covariate balance before and after IPTW weighting, demonstrating adequate balance in T stage (standardized mean differences < 0.1) following weighting. Weighted multivariable Cox re
This retrospective study found that for pancreatic neck cancer patients without preoperative radiographic evidence of GDA invasion, long-term survival in these patients depended more significantly on tumor biological characteristics (such as differentiation grade and T stage) and treatment-related factors (achieving R0 resection). This study’s univariate ana
This paradoxical observation-where broader resection in early-stage patients yields diminished survival benefits-may be attributable to the greater surgical trauma associated with TP, leading to prolonged postoperative recovery. Our data show that the TP group had the longest operative duration, highest intraoperative blood loss, and lengthiest postope
Lymph node dissection is a critical component of pancreatic neck cancer surgery[14-16]. Although PD and TP theoretically allow for more extensive lymphadenectomy than DP, this did not translate into a survival advantage[17-20]. In this study, both OS and DFS were superior in the PD and DP groups compared to the TP group in univariate analysis, though no statistically significant difference was observed in multivariate Cox analysis. Zheng et al[6] conducted a retrospective analysis of 160 patients with pancreatic neck cancer from the Surveillance, Epidemiology, and End Results (SEER) database who underwent curative resection (105 PD, 30 DP, and 25 TP cases) and found no significant differences in OS or cancer-specific survival among the three surgical approaches. Similar conclusions were reported by Nomura et al[7].
Despite the lack of statistical significance, the consistent trend toward inferior survival with TP relative to DP across different analytical methods (P approximately = 0.1) may signal a clinically relevant hazard, with point estimates sug
The lack of survival differences despite variations in lymphadenectomy extent may be related to the nodal metastasis patterns of pancreatic neck cancer. Although findings vary across studies, most reports indicate that the most common lymph node metastasis sites in pancreatic neck cancer include the common hepatic artery (#8), SMA (#14), and proximal splenic artery (#11p) regions-all of which can be adequately addressed in DP[4,5,7]. In our center, DP routinely includes dissection of stations #10, #11, and #18, supplemented by #7, #8, and #14 lymphadenectomy, with additional #9 dissection in cases of bulky tumors or proximity to the celiac axis. A large retrospective study of 846 patients from the National Cancer Database (2004-2020) found that while DP yielded fewer total lymph nodes and a lower positive node rate compared to PD and TP, multivariate analysis showed no survival difference between DP and PD, although TP was associated with worse outcomes than PD[19]. Therefore, for patients with pancreatic neck cancer eligible for R0 resection, DP appears to be the preferable choice when balancing surgical morbidity and long-term survival.
The conclusions of this study should be interpreted cautiously due to several limitations. The sample size was relatively small, particularly in the TP group (n = 26), which included only four early-stage TP cases, limiting statistical power. Thus, this limitation should be carefully considered when interpreting our findings. Additionally, as a single-center retrospective study, selection bias is inevitable. The lack of quality-of-life assessments-such as postoperative diabetes control, pancreatic enzyme replacement adherence, and other factors influencing survival-may also affect the reliability of the regression analysis.
In this study, the surgical procedure was determined intraoperatively at the surgeon’s discretion based on tumor extent and individual assessment; consequently, this cohort does not represent a comparison of interchangeable options for the same patient. Notably, patients in the TP group had larger tumors, a higher proportion of advanced-stage disease, and a lower rate of adjuvant chemotherapy. Although we employed multivariate Cox regression analysis and IPTW based on T stage to adjust for measured covariates, the non-randomized assignment of surgical procedures inevitably introduces the risk of residual confounding. Thus, the observed survival differences may be partially influenced by baseline imbalances that were not fully accounted for. This limitation should be carefully considered when interpreting our findings.
Furthermore, this retrospective dataset lacks detailed information regarding the specific chemotherapy regimen, treatment duration, dose intensity, and completion rate of postoperative adjuvant chemotherapy. These factors may influence survival outcomes and limit our ability to fully elucidate the reasons for the poorer prognosis observed in the TP group. Future multicenter prospective studies are needed to validate these findings.
In summary, although surgical procedure was not significantly associated with survival in the multivariable models (P > 0.05), the consistent trend toward inferior outcomes with TP relative to DP (P < 0.1) warrants cautious interpretation. Given the exploratory nature of these findings and the potential for reduced surgical trauma with DP, extending resection to PD or TP does not appear to confer a survival advantage when R0 clearance can be achieved by DP.
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