The feasibility and potential benefits of administering adjuvant chemotherapy in resected pancreatic cancer patients unable to promptly remove intraperitoneal drainage post-surgery: A retrospective cohort study

The feasibility and potential benefits of administering adjuvant chemotherapy in resected pancreatic cancer patients unable to promptly remove intraperitoneal drainage post-surgery: A retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The feasibility and potential benefits of administering adjuvant chemotherapy in resected pancreatic cancer patients unable to promptly remove intraperitoneal drainage post-surgery: A retrospective cohort study Dong Xu, Nan Lv, Qianqian Wang, Yang Wu, Kai Zhang, Yi Miao, Jishu Wei, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6003455/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 May, 2025 Read the published version in BMC Cancer → Version 1 posted 8 You are reading this latest preprint version Abstract Objective Pancreatectomy remains associated with a high incidence of complications. In certain cases, patients with pancreatic ductal adenocarcinoma (PDAC) face challenges in removing intraperitoneal drainage after surgery, leading to potential delays in the administration of adjuvant chemotherapy (AC) and potentially impacting survival outcomes. The objective of this study was to evaluate the feasibility and potential benefits of AC in PDAC patients who are unable to remove intraperitoneal drainage over 30 days. Methods Between January 2021 and December 2022, a total of 220 patients with resected PDAC received AC at our center. Among them, 84 patients experienced persistent intraperitoneal drainage lasting more than 30 days postoperatively. Of these, 38 patients (45.2%) initiated AC despite the ongoing presence of drainage and were classified as the AC(d+) group, while the remaining 46 patients (54.8%) began AC only after successful drainage removal, and were categorized as the AC(d−) group. The other 136 patients, who underwent prompt removal of intraperitoneal drainage, were assigned to the AC(pr) group. Baseline information, surgery-related outcomes, and chemotherapy-related adverse events were collected and compared between the two groups, and factors that affected recurrence-free survival (RFS) were also analysed. Results Of the 220 patients included in the study, 107 (48.7%) experienced grade 3–4 chemotherapy-related adverse events. The interval from surgery to the initiation of AC was similar between the AC(d+) and AC(pr) groups (50 vs. 57 days, P = 0.108). However, it was significantly shorter in the AC(d+) group compared to the AC(d−) group (50 vs. 61 days, P = 0.015). Notably, no additional chemotherapy-related adverse events were observed in the AC(d+) group compared to either the AC(d−) or AC(pr) groups. The estimated 1-year and 2-year survival rates were 85.6% and 60.5%, respectively, for the AC(d−) group, and 95.8% and 61.0% for the AC(d+) group. In the AC(pr) group, the corresponding survival rates were 89.1% and 64.0%. Cox multivariate regression analysis demonstrated that tumour grade differentiation, completed six cycles of therapy, the interval from surgery to the initiation of AC and resection margins were independent factors affecting RFS. Conclusion Administering AC was safe for patients who underwent resection for PDAC and encountered challenges in the prompt removal of intraperitoneal drainage beyond 30 days post-surgery. The proactive management of preventing delays in chemotherapy administration could reduce the early recurrence risk in this particular patient cohort. Pancreatic cancer Postoperative pancreatic fistula Intraperitoneal drainage Adjuvant chemotherapy Recurrence-free Survival Figures Figure 1 Introduction Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer with a dismal 5-year survival rate of less than 11%. 1 Despite the typically advanced stage upon diagnosis, patients undergoing primary tumour resection achieve the best outcomes. 2 The prevailing incidence of complications post pancreatectomy remains conspicuously high, underscored by the rate of occurrence of postoperative pancreatic fistula spanning from 5–26%. 3 This also contributes to the situation where numerous patients undergoing pancreatic cancer resection are unable to promptly remove the intraperitoneal drainage. Adjuvant chemotherapy (AC) following potentially curative resection is crucial in preventing early recurrence and improving overall survival (OS). 2 Based on the research from ESPAC-3, the ability to complete the full course of chemotherapy is more important than the timing of its initiation for the majority of pancreatic cancer patients. 4 However, for certain patients, such as those who were unable to complete the full course of chemotherapy as observed in the ESPAC-3 study, 4 or patients with R1/R2 resections, or individuals who test positive for postoperative circulating tumor cells, early chemotherapy might confer survival benefits. 4 , 5 In patients with complications, however, intraperitoneal drainage may need to be retained for more than 8 weeks, and in some cases up to 12 weeks, leading to a prolonged delay in the initiation of AC. 6 Additionally, it is essential to underscore that the patient’s eligibility for AC primarily depends on their performance status, good biliary drainage, and adequate nutritional intake. 7 Even in the presence of intraperitoneal drainage, provided that drainage is unobstructed and that these factors are met, AC may still be possible. Thus, the objective of this study was to evaluate the feasibility and potential benefits of AC in pancreatic cancer patients who are unable to remove intraperitoneal drainage for more than 30 days following surgery, subject to meeting other appropriate criteria. Materials and Methods Patient cohort There was performed a retrospective review of all patients who underwent radical resection for pancreatic cancer at the Pancreatic Centre of the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2022. The inclusion criteria comprised: (1) pathological confirmation of PDAC, (2)undergone radical resection. The exclusion criteria were as follows: (1) concurrent presence of other malignancies, (2) lack of AC after radical resection, and (3) major information missing. All patients signed an informed consent form, which was approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University. A total of 220 patients with PDAC who underwent radical resection and received AC were included in the study. Among them, 84 patients experienced persistent intraperitoneal drainage lasting more than 30 days postoperatively. Of these, 38 patients (45.2%) initiated AC despite the ongoing presence of drainage and were classified as the AC(d+) group, while the remaining 46 patients (54.8%) began AC only after successful removal of the drainage, and were categorized as the AC(d-) group. The other 136 patients, who underwent prompt removal of intraperitoneal drainage, were assigned to the AC(pr) group. Surgical procedure and intraperitoneal drainage placement (1) Pancreaticoduodenectomy (PD): Standard or extended pancreaticoduodenectomy is conducted, followed by reconstruction of the digestive tract via the Child method. A modified single-layer pancreatic duct–mucosa anastomosis is utilised for pancreatico-jejunal anastomosis. (2) Distal pancreatectomy (DP): Standard or extended distal pancreatectomy is conducted, comprising resection of the pancreatic tail, spleen, and splenic vessels, lymph node dissection, and closure of the pancreatic remnant by means of isolated ligation of the pancreatic duct followed by intermittent suture closure of the pancreatic remnant or a linear cutting stapler. (3) Following the conclusion of PD or DP, it is customary to insert 2–3 intraperitoneal drainage tubes in the vicinity of the pancreatico-jejunal anastomosis site or the pancreatic remnant for the purpose of drainage. Drainage removal criteria Amylase in the abdominal drainage fluid is tested on postoperative days 1, 3, and 5, and the characteristics of the drainage fluid are observed to determine the presence of pancreatic fistula, biliary fistula, or intestinal fistula. If no such fistulas are identified as described above, and the drainage fluid appears clear and resembles ascites, the drainage tube is typically removed between postoperative days 5–7. If the fistulas are present, but the patient: I. Remains in generally good condition with no fever; II. Displays relatively normal infection markers (WBC, PCT, CRP, etc.); III. Exhibits no abdominal fluid accumulation upon ultrasound/CT examination, it may be considered to discharge the patient without drainage removal, followed by regular follow-up appointments. After discharge with a drain in place, if there is minimal to no fluid output for 2–3 days (< 15-20ml/day), and the patient continues to meet criteria I, II, and III, it may be appropriate to consider the removal of drainage. Adjuvant regimen The chemotherapy protocol comprises first-line AC regimens, which consist of the mFOLFIRINOX regimen (irinotecan, oxaliplatin, calcium folinate, and 5-fluorouracil), gemcitabine (GEM) combined with capecitabine, or GEM monotherapy. Data collection Clinicopathological data were retrospectively collected from a prospectively maintained database as well as the electronic medical record. The pathological data collected included tumour grade differentiation, resection margins, and the American Joint Committee on Cancer (AJCC) 8th edition stage. Margin determination is based on the “Standardised Pathology Protocol” and the “1mm” principle. 8 Adverse reactions associated with chemotherapy were assessed using Common Terminology Criteria for Adverse Events Version 5.0 (CTCAE V5.0). Follow-up was updated until June 30, 2023. Recurrence-free survival (RFS) was evaluated using enhanced CT scans by radiologists and confirmed by experienced specialists in pancreatic tumors. Overall survival data was obtained through telephone interviews. Our study was approved by the ethics committee of the hospital, and informed consent was obtained from all patients. Statistics Data analysis was performed using the SPSS 26.0 software program and R software version 4.2.0 ( http://www.r-project.org/ ). Normally-distributed continuous variables were presented as mean ± standard deviation and compared using independent t-tests. Non-normally-distributed continuous variables were presented as median (interquartile range) [M(QR)] and compared using the Mann–Whitney U test. Categorical variables were presented as percentages and compared using the χ² test or Fisher’s exact test. Kaplan-Meier analysis was employed to construct the recurrence-free survival (RFS) curve using the R software. Univariate and multivariate RFS survival analyses were conducted using Cox proportional-hazards regression models. The significance level was established at α = 0.05, with P < 0.05 denoting statistical significance. Results Patient characteristics A total of 220 patients were included in the study, specifically 135 males (61.4%) and 85 females (38.6%), with a median age of 61 ± 9 years. Among them, 126 cases (57.3%) had undergone PD&PPPD surgery, and 94 cases (42.7%) had undergone DP surgery, with a median operation time of 235 (190, 290) minutes and an estimated intraoperative blood loss of 200 (150, 400) ml. The resection margins were as follows: R0 in 95 cases (43.2%), R1 < 1mm in 88 cases (40.0%), and R1-direct in 14 cases (6.4%). The median postoperative hospital stay was 15 (12, 24) days. The interval from surgery to the initiation of AC was similar between the AC(d+) and AC(pr) groups (50 vs. 57 days, P = 0.108), but significantly shorter in the AC(d+) group compared to the AC(d−) group (50 vs. 61 days, P = 0.015). However, patients in the AC(d+) group had a longer interval from surgery to drainage removal compared to those in the AC(d−) group (89 vs. 42 days, P < 0.001). Additionally, a smaller proportion of patients in the AC(pr) group underwent distal pancreatectomy compared to those in the AC(d+) group. There were no statistically significant differences in other baseline characteristics, as demonstrated in Table 1 . Table 1 Demographics, Tumour Characteristics, Surgical-related Data of AC(d+) and AC(d-) Patients Factor AC(d+) (n = 38) AC(d-) (n = 46) AC(pr) (n = 136) P- value (d + vs d-) P-value (d + vs pr) Age, years, m ± sd 60 ± 7 58 ± 10 62 ± 9 0.323 0.158 Sex, n (%) 0.569 0.127 Male 27 (71.1) 30 (65.2) 78 (57.4) Female 11 (28.9) 16 (34.8) 58 (42.6) Preoperative CA 19 − 9 (U/ml), M(QR) 111 (47, 404) 140 (44, 473) 129 (53, 299) 0.464 0.688 Operation type, n (%) 0.933 0.026 Pancreaticoduodenectomy 17 (44.7) 21 (45.7) 88 (64.7) Distal pancreatectomy 21 (55.3) 25 (54.3) 48 (35.3) Operation time (min), M(QR) 235 (186, 297) 240 (198, 296) 230 (190, 289) 0.951 0.914 Intraoperative blood loss (ml), M(QR) 200 (100, 500) 200 (100, 300) 200 (150, 400) 0.901 0.899 Tumor grade differentiation, n (%) 0.497 0.688 Well 0 0 2 (1.5) Moderate 17 (44.7) 24 (52.2) 54 (39.7) Poor 21 (55.3) 22 (47.8) 80 (58.5) # Resection margins, n (%) 0.469 0.612 R0 18 (48.6) 14 (37.8) 63 (51.2) R1 < 1mm 16 (43.2) 17 (45.9) 55 (44.7) R1-direct 3 (8.1) 6 (16.2) 5 (4.1) # T stage, n (%) 0.054 0.330 T1 9 (23.7) 3 (6.5) 15 (12.3) T2 12 (31.6) 22 (47.8) 52 (42.6) T3 11 (28.9) 18 (39.1) 37(30.3) T4 6 (15.8) 3 (6.5) 18 (14.8) N stage, n (%) 0.791 0.647 N0 14 (36.8) 19 (41.3) 58 (42.6) N1 18 (47.4) 22 (47.8) 53 (39.0) N2 6 (15.8) 5 (10.9) 25 (18.4) # AJCC 8th stage, n (%) 0.091 0.298 I 8 (21.1) 9 (19.6) 40 (32.8) II 18 (47.7) 31 (67.4) 55 (45.1) III 12 (31.6) 6 (13.0) 27 (22.1) Causes of inability to remove drainage 0.593 NA POPF 33 (86.8) 38 (82.6) NA Other causes 5 (13.2) 8 (17.4) NA Postoperative hospital stay (d), M(QR) 15 (13, 36) 16 (11, 23) 15 (12, 25) 0.333 0.457 AC regimen 1.000 0.669 Gemcitabine-based 27 (71.1) 32 (69.6) 103 (75.7) mFFX-based 8 (21.1) 10 (21.7) 27 (19.9) mFFX-gemcitabine combination 3 (7.9) 4 (8.7) 6 (4.4) ECOG performance status at initiating AC, n (%) 0.279 0.914 0 12 (31.6) 12 (26.1) 48 (35.3) 1 22 (57.9) 23 (50.0) 72 (52.8) 2 4 (10.5) 11 (23.9) 16 (11.9) Interval from surgery to drainage removal (d), M(QR) 89 (68, 111) 42 (33, 55) 14 (8, 23) < 0.001 < 0.001 Interval from surgery to initiation of AC (d), M(QR) 50 (44, 65) 61 (50, 78) 57 (48, 66) 0.015 0.108 Completed six cycles of AC, n (%) 0.695 0.452 Yes 31 (81.6) 39 (84.8) 119 (87.5) No 7 (18.4) 7 (15.2) 17 (12.5) ECOG, Eastern Cooperative Oncology Group; mFFX, mFOLFIRINOX; NA, Not Available; AC, Adjuvant Chemotherapy; # Missing data exist Comparison of chemotherapy-related adverse reactions Of the 220 patients in the study, 107 (48.7%) experienced grade 3–4 chemotherapy-related adverse events, with neutropenia being the most common, occurring in 64 patients (29.1%). Other grade 3–4 adverse events included sensory peripheral neuropathy in 45 patients (20.1%), abdominal infection in 35 patients (15.9%), thrombocytopenia in 29 patients (13.2%), fatigue in 26 patients (11.8%), and anemia in 20 patients (9.1%). No significant differences in new-onset surgery-related complications, including hemorrhage, ileus, and abdominal infection, were observed between the AC(d+) group and either the AC(d−) or AC(pr) groups. Additionally, no significant differences were observed in the incidence of grade 3–4 chemotherapy-related adverse events. A more detailed description of these adverse events is provided in Table 2 . Table 2 Comparison of Grade 3–4 Chemotherapy-Related Adverse Events Among Different Groups Event AC(d+) (n = 38) AC(d-) (n = 46) AC(pr) (n = 136) P-value (d + vs. d-) P-value (d + vs. pr) Hematologic event Anemia 2 (5.3) 4 (8.7) 14 (10.3) 0.685 0.528 Leukopenia 4 (10.5) 5 (10.9) 20 (14.7) 1.000 0.789 Neutropenia 12 (31.6) 14 (30.4) 38 (27.9) 0.910 0.661 Thrombocytopenia 5 (13.2) 4 (8.7) 20 (14.7) 0.725 0.810 Febrile neutropenia 1 (2.6) 4 (8.7) 8 (5.9) 0.372 0.686 Nonhematologic event Abdominal infection 8 (21.1) 9 (19.6) 18 (13.2) 0.866 0.232 Infection of other sites 4 (10.5) 3 (6.5) 12 (8.8) 0.696 0.754 Hemorrhage 2 (5.3) 1 (2.2) 10 (7.4) 0.587 1.000 Ileus 1 (2.6) 4 (8.7) 8 (5.9) 0.372 0.686 Fatigue 6 (15.8) 4 (8.7) 16 (11.8) 0.337 0.581 Nausea 3 (7.9) 5 (10.9) 9 (6.6) 0.724 0.726 Vomiting 2 (5.3) 5 (10.9) 7 (5.1) 0.449 1.000 Diarrhea 4 (10.5) 3 (6.5) 4 (2.9) 0.696 0.070 Constipation 3 (7.9) 2 (4.3) 7 (5.1) 0.654 0.457 Fever 1 (2.6) 2 (4.3) 14 (10.3) 1.000 0.196 Sensory peripheral neuropathy 10 (26.3) 6 (13.0) 29 (21.3) 0.123 0.514 Biochemical event ALT/AST increased 1 (2.6) 3 (6.7) 9 (6.6) 0.621 0.693 ALP/γ-GGT increased 2 (5.3) 3 (6.5) 11 (8.1) 1.000 0.736 Blood total bilirubin increased 1 (2.6) 2 (4.3) 8 (5.9) 1.000 0.686 Hypoalbuminemia 0 0 5 (3.7) / 0.587 Creatinine increased 0 0 0 / / APTT prolonged 0 0 0 / / ALT, alanine aminotrans-ferase level; AST, aspartate aminotrans-ferase level;ALP, alkaline phosphatase level; γ-GGT, γ-glutamyltransferase level. Activated partial thromboplastin time Survival analysis In June 2023, with a median follow-up duration of 17.0 (14.6, 19.4) months, 101 patients (45.9%) were observed to have local recurrence and/or distant metastasis, and the median RFS was 18.7 (95% CI, 15.3–22.1) months. A total of 43 deaths (19.5%) were observed during the follow-up period, including eight patients in the AC(d−) group, eight patients in the AC(d+) group, and 27 patients in the AC(pr) group. The estimated 1-year and 2-year survival rates were 85.6% and 60.5%, respectively, for the AC(d−) group, and 95.8% and 61.0% for the AC(d+) group. In the AC(pr) group, the corresponding survival rates were 89.1% and 64.0%. The median OS endpoint has not been attained as of the current analysis. Cox univariate regression analysis revealed that the tumour grade differentiation, resection margins, AJCC 8th stage, the interval from surgery to the initiation of AC, and completed six cycles of chemotherapy were significantly associated with RFS (P < 0.05). Detailed results are presented in Table 3 . Cox multivariate regression analysis unveiled that tumour grade differentiation, completed six cycles of therapy, the interval from surgery to the initiation of AC and resection margins were independent factors affecting RFS. Detailed results are presented in Table 4 , and Fig. 1 illustrates the RFS curves. Table 3 Univariate Cox Proportional Hazards Models (n = 220) Factor No. of Patients No. of Recurrence Median RFS Time HR (95% CI) P-value Age, years Continuous variable 0.162 Sex Female 135 58 17.5 (10.3–24.7) Male 85 43 18.9 (16.5–21.2) 1.126 (0.757–1.674) 0.295 Preoperative CA 19 − 9 (U/ml) Continuous variable 0.179 Surgery Pancreaticoduodenectomy 126 55 21.2 (16.7–25.7) Distal pancreatectomy 94 46 16.1 (12.7–19.5) 1.353 (0.908–2.016) 0.137 * Tumor grade differentiation Moderate 95 28 21.7 (12.5–30.8) Poor 123 73 14.2 (10.3–18.1) 2.001 (1.294–3.097) 0.001 # Resection margins R0 95 35 23.3 (18.0-28.6) R1 < 1mm 88 35 21.0 (12.9–29.1) 1.478 (0.922–2.370) 0.105 R1-direct 14 11 9.9 (6.1–13.7) 3.289 (1.660–6.519) 0.001 # AJCC 8th stage I 55 20 21.7 (9.7–33.7) II 102 47 18.9 (13.3–24.5) 1.433 (0.846–2.424) 0.181 III 47 25 13.0 (10.2–15.9) 2.321(1.280–4.208) 0.006 ECOG performance status at initiating AC 0 24 13 22.4 (8.5–36.3) 1 45 20 24.2 (8.9–40.1) 0.809 (0.404–1.622) 0.551 2 15 10 14.2 (6.3–22.1) 1.363 (0.596–3.118) 0.436 AC regimen Gemcitabine-based 162 77 18.7 (16.3–20.1) mFFX-based 45 17 25.0 (9.1–40.9) 0.859 (0.508–1.455) 0.573 mFFX-gemcitabine combination 13 7 14.1 (13.6–14.5) 1.296 (0.596–2.814) 0.513 AC (d+) No 182 85 18.7 (15.7–21.6) Yes 38 16 23.2 (11.7–34.7) 0.970 (0.567–1.659) 0.911 Interval from surgery to drainage removal (d) Continuous variable 0.521 Interval from surgery to initiation of AC (d) Continuous variable 0.023 Completed six cycles of therapy No 31 22 8.9 (2.5–15.3) Yes 189 79 18.9 (15.5–22.3) 0.415 (0.258–0.668) < 0.001 ECOG, Eastern Cooperative Oncology Group; mFFX, FOLFIRINOX; AC, Adjuvant Chemotherapy; * Two well-differentiated tumors were excluded from analysis; # Missing data exist Table 4 Multivariate Cox Proportional Hazards Models (n = 220) Factor SE Wald HR(95% CI) P-value Interval from surgery to initiation of AC 0.005 4.916 1.012 (1.001–1.023) 0.027 Tumor grade differentiation 0.269 11.690 2.510 (1.481–4.254) 0.001 Resection margin 0.175 10.032 1.740 (1.235–2.451) 0.002 AJCC 8th stage 0.178 2.932 1.356 (0.957–1.922) 0.087 Completed six cycles of therapy 0.292 7.771 0.443 (0.250–0.785) 0.005 Discussion Despite a relatively high overall incidence of complications following pancreatic surgery, advances in the management and understanding of complications have led to significant decreases in mortality and reoperation rates, 9 , 10 enabling the possibility of administering AC without the removal of intraperitoneal drainage. Our findings, for the first time, indicate that there was no increase in the incidence of grade 3–4 adverse reactions and new-onset surgery-related complications associated with AC(d+) treatment. These preliminary results suggest that AC(d+) is a safe and feasible treatment approach for patients who are unable to remove intraperitoneal drainage following pancreatic cancer resection. Before proceeding with AC(d+), careful consideration ought to be given to two critical factors. Firstly, the patient’s physical and nutritional status should be assessed. Patients with a poor physical or nutritional status are typically advised to receive enteral nutrition either in the hospital or at home. Secondly, the possibility of obstructed abdominal fluid drainage should be ruled out, with imaging examinations serving as the primary method of assessment. In cases where fluid accumulation is detected around the drainage tube, it may be necessary to either replace the tube or withdraw it by 1–2cm. Conversely, if the fluid accumulation is remote from the drainage tube, percutaneous puncture drainage may be considered. The incidence of granulocytopenia following AC for pancreatic cancer ranges from 23.0–77.8%, with granulocyte deficiency occurring in approximately 5.4–22.2% of cases. 11 – 14 When combined with infection, this condition carries a high mortality rate. To prevent granulocyte deficiency in high-risk patients (e.g. those with low baseline white blood cell counts, liver dysfunction, or high ECOG scores) before AC(d+), proactive measures such as nutritional support and prophylactic use of G-CSF should be considered. In the case of granulocyte deficiency and infection, blood and drainage cultures for bacteria ought to be performed, followed by the administration of broad-spectrum antibiotics and G-CSF. Interestingly, chemotherapy drugs have the potential to induce the degeneration of pancreatic cells, widespread lobular atrophy, tissue fibrosis, and diminished exocrine pancreatic function, which could potentially lead to a decrease in the secretion of pancreatic fluid. 15 – 17 This effect might well be influenced by the specific chemotherapy regimen. 5-Fu has demonstrated efficacy in treating acute pancreatitis and refractory pancreatic fistula, 18 – 20 whilst gemcitabine-based regimen do not have this effect. In this study, AC(d+) did not shorten the duration of drainage. The interval from surgery to drainage removal was significantly longer in the AC(d+) group compared to the AC(d−) group (89 days vs. 42 days, P < 0.001). The high proportion (70.2%) of gemcitabine-based regimens used in the AC(d+) group may have contributed to this finding. Further analysis revealed that in the AC(d+) group, the duration of drainage for patients receiving the mFOLFIRINOX-based regimen was notably shorter than for those receiving the gemcitabine-based regimen (55 days vs. 64 days, P = 0.062), although this difference did not reach statistical significance. Additionally, existing literature suggests that chemotherapy may impair the healing of fistulas, which could be an important factor contributing to prolonged drainage time. 21 To determine which factor plays a more significant role, additional large-scale controlled trials are needed to validate these findings. In the CONKO-001 study, chemotherapy was initiated between days 10 and 42 postoperatively. 22 Shortly thereafter, the ESPAC-3 and ESPAC-4 trials initiated chemotherapy within 12 weeks based on expert consensus. 23 , 24 Consequently, the NCCN guidelines suggest initiating AC within 12 weeks after adequate recovery from surgery. 7 However, some patients may experience delayed initiation of AC beyond 12 weeks due to the inability to remove the abdominal drainage. Moreover, despite current guidelines recommending AC initiation within 12 weeks after surgery, several studies have reported a poorer prognosis in patients with delayed initiation of AC within this timeframe. 25 , 26 Sung Jun et al. 25 found that patients with stage I–II pancreatic cancer who commenced adjuvant therapy 28–59 days following primary surgical resection exhibited a superior 2-year survival rate (51.3% vs. 45.4%, P = 0.01) and OS (22.4 vs. 20.4 months, P = 0.01) in comparison with those who initiated adjuvant treatment before 28 days or after 59 days. In a study conducted by Richard et al., 26 propensity score matching analysis revealed a significant association between earlier delivery (< 66 days) of AC and improved survival in patients with stage I–III pancreatic cancer. The 5-year survival rate was 20% in patients who received AC within 66 days in comparison to 18% in those who did not (P = 0.0266). For patients with a high risk of recurrence, early administration of chemotherapy may offer potential survival benefits. 5 The data from the ESPAC-3 study indicated that the ability to complete six cycles of AC is an independent prognostic factor for survival in pancreatic cancer, which aligns with our findings. However, in that study, for patients unable to complete all six cycles of chemotherapy, the timing of chemotherapy initiation emerged as an independent factor influencing both disease-free survival (DFS) and overall survival (OS). 3 Recent studies have also found that, for pancreatic cancer patients who are positive for postoperative circulating tumour cells, delaying chemotherapy significantly shortens the time to RFS (12.4 vs. 17.9 months, P = 0.004). 5 Moreover, despite the controversy surrounding the issue, several studies have suggested that POPF is a significant risk factor for high recurrence rates in patients with pancreatic cancer. 16 , 27 – 31 A meta-analysis conducted by Grego et al. (2021) reported a 59% increased risk of tumour recurrence in patients with pancreatic cancer who developed POPF. 29 Likewise, Nagai et al. 28 discovered that pancreatic fistula after surgery was associated with a four times higher risk of peritoneal recurrence. Multivariate analysis in this study demonstrated that the interval from surgery to the initiation of AC is an independent factor affecting RFS. AC(d+) may be more warranted in this particular patient population. Additionally, Our study identified tumor differentiation and resection margin status as independent prognostic factors for survival, consistent with previous literature. Well-differentiated tumors typically indicate less aggressive biology and better outcomes, while negative resection margins reflect more complete tumor clearance and improved prognosis. Carlo Ingaldi et al. reported that well-differentiated tumors (G1), R0 resections, and adjuvant chemotherapy were all associated with longer survival (p = 0.010, 0.019, and 0.052, respectively).. 32 Similarly, Yamamoto et al. identified R0 resection as an independent favorable prognostic factor (HR = 0.48; 95% CI: 0.30–0.77; P = 0.003). 33 Luu AM et al. also confirmed tumor grade as an independent predictor of survival in PDAC, underscoring its value in postoperative risk stratification. 34 There exist certain limitations in this study. Firstly, our study was constrained by a limited sample size and a retrospective design. Although the baseline characteristics of the two groups are comparable, there remains a potential for residual confounding. Secondly, our study preliminarily demonstrates the safety and feasibility of AC(d+), while analyzing the factors influencing RFS. However, a long-term survival analysis is still required, and extended follow-up is essential to ascertain enduring survival outcomes. Conclusion Administering AC was safe for patients who underwent resection for PDAC and encountered challenges in the prompt removal of intraperitoneal drainage beyond 30 days post-surgery. The proactive management of preventing delays in chemotherapy administration could reduce the early recurrence risk in this particular patient cohort. Declarations Ethics approval Ethics approval This study was approved by the Ethics Committee of the First Affiliated Hospital with Nanjing Medical University. Consent to participate All patients signed an informed consent form. Funding This study was supported by National Natural Science Foundation of China (No.82072706). Competing interests The authors declare no competing interests. Author Contribution Dong Xu designed the study, collected and analyzed the data, and drafted the manuscript. Min Tu and Nan Lv contributed to data collection and analysis. Qianqian Wang and Yang Wu assisted in data interpretation and manuscript revision. Kai Zhang provided statistical support and contributed to data analysis. Yi Miao participated in the study design and provided critical revisions. Jishu Wei , Min Tu and Kuirong Jiang, as corresponding authors, supervised the study, provided critical intellectual input, and revised the manuscript for important content. All authors read and approved the final version of the manuscript. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Siegel RL, et al. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7–33. Halbrook CJ, et al. Pancreatic cancer: Advances and challenges. Cell. 2023;186(8):1729–54. Marchegiani G, Bassi C. Prevention, prediction, and mitigation of postoperative pancreatic fistula. Br J Surg. 2021;108(6):602–4. Valle JW, et al. Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study. J Clin Oncol. 2014;32(6):504–12. Javed AA et al. A Delay in Adjuvant Therapy is Associated with Worse Prognosis only in Patients with Transitional Circulating Tumor Cells Following Resection of Pancreatic Ductal Adenocarcinoma. Ann Surg, 2022. Bonaroti JW, et al. Impact of postoperative pancreatic fistula on long-term oncologic outcomes after pancreatic resection. HPB (Oxford). 2021;23(8):1269–76. National Comprehensive Cancer Network. (NCCN) Clinical Practice Guidelines in Oncology.Pancreatic Adenocarcinoma, Version 1. 2023. https://www.nccn.org/guidelines/guidelines-detail?category=1 &id=1455. Accessed 15 April 2023. In. Bockhorn M, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2014;155(6):977–88. Kokkinakis S, et al. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int. 2022;21(6):527–37. Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015;220(4):530–6. Ito G, et al. Risk factors for severe neutropenia in pancreatic cancer patients treated with gemcitabine/nab-paclitaxel combination therapy. PLoS ONE. 2021;16(7):e0254726. Irisawa A, et al. Incidence of and risk factors for severe neutropenia during treatment with the modified FOLFIRINOX therapy in patients with advanced pancreatic cancer. Sci Rep. 2022;12(1):15574. Keum J, et al. Single-center risk factor analysis for FOLFIRINOX associated febrile neutropenia in patients with pancreatic cancer. Cancer Chemother Pharmacol. 2020;85(4):651–9. Saito Y, et al. Detection of risk factors related to administration suspension and severe neutropenia in gemcitabine and nab-paclitaxel treatment. Support Care Cancer. 2021;29(6):3277–85. Kalimuthu SN, et al. The spectrum of histopathological changes encountered in pancreatectomy specimens after neoadjuvant chemoradiation, including subtle and less-well-recognised changes. J Clin Pathol. 2016;69(6):463–71. Hank T, et al. Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy. JAMA Surg. 2019;154(10):943–51. Dahdaleh FS, et al. Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis. J Gastrointest Surg. 2021;25(3):747–56. Georgescu T et al. [5-fluorouracil treatment of acute pancreatitis and of pancreatic and duodenal fistulae]. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir, 1990. 39(1): pp. 45–50. Constantinescu C, Puiu R, Straja D. [5-Fluorouracil (ftorafur) in the treatment of acute pancreatitis. Indications for and efficacy of its use]. Rev Med Interna Neurol Psihiatr Neurochir Dermatovenerol Med Interna, 1989. 41(5): pp. 443-8. Kubyshkin VA, Chzhao AV, Chugunov AO. [5-fluorouracil in the treatment and prevention of acute pancreatitis]. Vestn Khir Im I I Grek. 1982;129(8):132–4. Slonimska P, et al. Chemotherapy-Mediated Complications of Wound Healing: An Understudied Side Effect. Adv Wound Care (New Rochelle). 2024;13(4):187–99. Oettle H, et al. Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA. 2013;310(14):1473–81. Neoptolemos JP, et al. Effect of adjuvant chemotherapy with fluorouracil plus folinic acid or gemcitabine vs observation on survival in patients with resected periampullary adenocarcinoma: the ESPAC-3 periampullary cancer randomized trial. JAMA. 2012;308(2):147–56. Neoptolemos JP, et al. Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet. 2017;389(10073):1011–24. Ma SJ, et al. Association of Timing of Adjuvant Therapy With Survival in Patients With Resected Stage I to II Pancreatic Cancer. JAMA Netw Open. 2019;2(8):e199126. White RJ, et al. Time to Adjuvant Systemic Therapy Following Pancreatic Cancer Resection and Effect on Outcome. Pancreas. 2019;48(8):1086–91. Veillette G, et al. Implications and management of pancreatic fistulas following pancreaticoduodenectomy: the Massachusetts General Hospital experience. Arch Surg. 2008;143(5):476–81. Nagai S, et al. Recurrence pattern and prognosis of pancreatic cancer after pancreatic fistula. Ann Surg Oncol. 2011;18(8):2329–37. Grego A et al. Does Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis. Cancers (Basel), 2021. 13(22). Uchida Y, et al. Postoperative pancreatic fistulas decrease the survival of pancreatic cancer patients treated with surgery after neoadjuvant chemoradiotherapy: A retrospective analysis. Surg Oncol. 2020;35:527–32. Watanabe Y, et al. Effect of postoperative major complications on prognosis after pancreatectomy for pancreatic cancer: a retrospective review. Surg Today. 2017;47(5):555–67. Ingaldi C, et al. Clinicopathological predictive factors in long-term survivors who underwent surgery for pancreatic ductal adenocarcinoma: A single-center propensity score matched analysis. World J Surg. 2024;48(12):3001–13. Yamamoto T, et al. Long-term survival after resection of pancreatic cancer: a single-center retrospective analysis. World J Gastroenterol. 2015;21(1):262–8. Luu AM, et al. Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int. 2021;20(3):271–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 May, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Accepted 02 May, 2025 Reviews received at journal 30 Apr, 2025 Reviews received at journal 29 Apr, 2025 Reviewers agreed at journal 14 Apr, 2025 Reviewers agreed at journal 12 Apr, 2025 Reviewers invited by journal 10 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 08 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6003455","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":441015997,"identity":"0ec4fd21-d976-4f42-bd50-dc2b4d26c99f","order_by":0,"name":"Dong Xu","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"","lastName":"Xu","suffix":""},{"id":441015998,"identity":"33163d20-10c5-4fa6-8c88-065d56ce9566","order_by":1,"name":"Nan Lv","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Lv","suffix":""},{"id":441015999,"identity":"8837409e-6ebd-4241-84f8-fedd0f121982","order_by":2,"name":"Qianqian Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qianqian","middleName":"","lastName":"Wang","suffix":""},{"id":441016000,"identity":"9f93e171-0a3b-41c7-bc51-c18344503bcd","order_by":3,"name":"Yang Wu","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Wu","suffix":""},{"id":441016001,"identity":"7deca7f5-9f99-41e6-84a0-6a46766845b3","order_by":4,"name":"Kai Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical 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Tu","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Tu","suffix":""},{"id":441016008,"identity":"592dc73c-aaaf-4345-a1f0-624f6f9ab629","order_by":8,"name":"Kuirong Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACxmYQeYCBB8z7wMAGpiWI1sI4gxgtEHAAQjHzQPl4tTC3Mz97+OXMYRnz9t7Dr2138EUbHGA+eJuHwS4Pt8PYzI1lbhzmkTlzLs069wxb7oYDbMnWPAzJxXj8YiYt8eEwj4REjplxbhtIC4+ZNA/DgcQGnFrYvyG0WIK18H8joIXHTPLDDbAW48eMEFvYCGkpk2Y4k84jwXPGjLEXqGXmYTZjyzkGyTi1GPYf3yb545i1vQR7j/GHn23HcvuONz+88abCDreWBkR0sAGj4xiQC2Ib4FAPBPIgx/2AsJk/MDDU4FY6CkbBKBgFIxYAAEieU90YvdRKAAAAAElFTkSuQmCC","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital), Pancreas Research Institute, Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Kuirong","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2025-02-11 04:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6003455/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6003455/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-14262-1","type":"published","date":"2025-05-20T15:58:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80580287,"identity":"1884090a-7385-4ad0-bb99-b8e8666e58c3","added_by":"auto","created_at":"2025-04-14 23:14:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85777,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan Meier plots for RFS by (A) Interval from surgery to chemotherapy (\u0026lt; 60 days vs. ≥ 60 days), (B) Tumor differentiation (well vs. moderate vs. poor), (C) Completed six cycles of chemotherapy (No vs. Yes), (D) Resection margin (R0 vs. R1\u0026lt;1mm vs. R1-direct).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6003455/v1/3f0e3434225dfc0ef7829696.png"},{"id":83460158,"identity":"a66f407f-e5ff-4f4c-b7c6-dae84c9a40af","added_by":"auto","created_at":"2025-05-26 16:11:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1341817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6003455/v1/bc2b4d03-e48a-47eb-bfca-e36452f4e6a2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The feasibility and potential benefits of administering adjuvant chemotherapy in resected pancreatic cancer patients unable to promptly remove intraperitoneal drainage post-surgery: A retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer with a dismal 5-year survival rate of less than 11%.\u003csup\u003e1\u003c/sup\u003e Despite the typically advanced stage upon diagnosis, patients undergoing primary tumour resection achieve the best outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The prevailing incidence of complications post pancreatectomy remains conspicuously high, underscored by the rate of occurrence of postoperative pancreatic fistula spanning from 5\u0026ndash;26%.\u003csup\u003e3\u003c/sup\u003e This also contributes to the situation where numerous patients undergoing pancreatic cancer resection are unable to promptly remove the intraperitoneal drainage.\u003c/p\u003e \u003cp\u003eAdjuvant chemotherapy (AC) following potentially curative resection is crucial in preventing early recurrence and improving overall survival (OS).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Based on the research from ESPAC-3, the ability to complete the full course of chemotherapy is more important than the timing of its initiation for the majority of pancreatic cancer patients.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, for certain patients, such as those who were unable to complete the full course of chemotherapy as observed in the ESPAC-3 study, \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e or patients with R1/R2 resections, or individuals who test positive for postoperative circulating tumor cells, early chemotherapy might confer survival benefits. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn patients with complications, however, intraperitoneal drainage may need to be retained for more than 8 weeks, and in some cases up to 12 weeks, leading to a prolonged delay in the initiation of AC.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Additionally, it is essential to underscore that the patient\u0026rsquo;s eligibility for AC primarily depends on their performance status, good biliary drainage, and adequate nutritional intake.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Even in the presence of intraperitoneal drainage, provided that drainage is unobstructed and that these factors are met, AC may still be possible.\u003c/p\u003e \u003cp\u003eThus, the objective of this study was to evaluate the feasibility and potential benefits of AC in pancreatic cancer patients who are unable to remove intraperitoneal drainage for more than 30 days following surgery, subject to meeting other appropriate criteria.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient cohort\u003c/h2\u003e \u003cp\u003e There was performed a retrospective review of all patients who underwent radical resection for pancreatic cancer at the Pancreatic Centre of the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2022. The inclusion criteria comprised: (1) pathological confirmation of PDAC, (2)undergone radical resection. The exclusion criteria were as follows: (1) concurrent presence of other malignancies, (2) lack of AC after radical resection, and (3) major information missing. All patients signed an informed consent form, which was approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University.\u003c/p\u003e \u003cp\u003eA total of 220 patients with PDAC who underwent radical resection and received AC were included in the study. Among them, 84 patients experienced persistent intraperitoneal drainage lasting more than 30 days postoperatively. Of these, 38 patients (45.2%) initiated AC despite the ongoing presence of drainage and were classified as the AC(d+) group, while the remaining 46 patients (54.8%) began AC only after successful removal of the drainage, and were categorized as the AC(d-) group. The other 136 patients, who underwent prompt removal of intraperitoneal drainage, were assigned to the AC(pr) group.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedure and intraperitoneal drainage placement\u003c/h3\u003e\n\u003cp\u003e(1) Pancreaticoduodenectomy (PD): Standard or extended pancreaticoduodenectomy is conducted, followed by reconstruction of the digestive tract via the Child method. A modified single-layer pancreatic duct\u0026ndash;mucosa anastomosis is utilised for pancreatico-jejunal anastomosis. (2) Distal pancreatectomy (DP): Standard or extended distal pancreatectomy is conducted, comprising resection of the pancreatic tail, spleen, and splenic vessels, lymph node dissection, and closure of the pancreatic remnant by means of isolated ligation of the pancreatic duct followed by intermittent suture closure of the pancreatic remnant or a linear cutting stapler. (3) Following the conclusion of PD or DP, it is customary to insert 2\u0026ndash;3 intraperitoneal drainage tubes in the vicinity of the pancreatico-jejunal anastomosis site or the pancreatic remnant for the purpose of drainage.\u003c/p\u003e\n\u003ch3\u003eDrainage removal criteria\u003c/h3\u003e\n\u003cp\u003eAmylase in the abdominal drainage fluid is tested on postoperative days 1, 3, and 5, and the characteristics of the drainage fluid are observed to determine the presence of pancreatic fistula, biliary fistula, or intestinal fistula. If no such fistulas are identified as described above, and the drainage fluid appears clear and resembles ascites, the drainage tube is typically removed between postoperative days 5\u0026ndash;7.\u003c/p\u003e \u003cp\u003eIf the fistulas are present, but the patient: I. Remains in generally good condition with no fever; II. Displays relatively normal infection markers (WBC, PCT, CRP, etc.); III. Exhibits no abdominal fluid accumulation upon ultrasound/CT examination, it may be considered to discharge the patient without drainage removal, followed by regular follow-up appointments.\u003c/p\u003e \u003cp\u003eAfter discharge with a drain in place, if there is minimal to no fluid output for 2\u0026ndash;3 days (\u0026lt;\u0026thinsp;15-20ml/day), and the patient continues to meet criteria I, II, and III, it may be appropriate to consider the removal of drainage.\u003c/p\u003e\n\u003ch3\u003eAdjuvant regimen\u003c/h3\u003e\n\u003cp\u003eThe chemotherapy protocol comprises first-line AC regimens, which consist of the mFOLFIRINOX regimen (irinotecan, oxaliplatin, calcium folinate, and 5-fluorouracil), gemcitabine (GEM) combined with capecitabine, or GEM monotherapy.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eClinicopathological data were retrospectively collected from a prospectively maintained database as well as the electronic medical record. The pathological data collected included tumour grade differentiation, resection margins, and the American Joint Committee on Cancer (AJCC) 8th edition stage. Margin determination is based on the \u0026ldquo;Standardised Pathology Protocol\u0026rdquo; and the \u0026ldquo;1mm\u0026rdquo; principle.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Adverse reactions associated with chemotherapy were assessed using Common Terminology Criteria for Adverse Events Version 5.0 (CTCAE V5.0).\u003c/p\u003e \u003cp\u003eFollow-up was updated until June 30, 2023. Recurrence-free survival (RFS) was evaluated using enhanced CT scans by radiologists and confirmed by experienced specialists in pancreatic tumors. Overall survival data was obtained through telephone interviews.\u003c/p\u003e \u003cp\u003e Our study was approved by the ethics committee of the hospital, and informed consent was obtained from all patients.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eData analysis was performed using the SPSS 26.0 software program and R software version 4.2.0 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.r-project.org/\u003c/span\u003e\u003cspan address=\"http://www.r-project.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Normally-distributed continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared using independent t-tests. Non-normally-distributed continuous variables were presented as median (interquartile range) [M(QR)] and compared using the Mann\u0026ndash;Whitney U test. Categorical variables were presented as percentages and compared using the χ\u0026sup2; test or Fisher\u0026rsquo;s exact test. Kaplan-Meier analysis was employed to construct the recurrence-free survival (RFS) curve using the R software. Univariate and multivariate RFS survival analyses were conducted using Cox proportional-hazards regression models. The significance level was established at α\u0026thinsp;=\u0026thinsp;0.05, with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 denoting statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eA total of 220 patients were included in the study, specifically 135 males (61.4%) and 85 females (38.6%), with a median age of 61\u0026thinsp;\u0026plusmn;\u0026thinsp;9 years. Among them, 126 cases (57.3%) had undergone PD\u0026amp;PPPD surgery, and 94 cases (42.7%) had undergone DP surgery, with a median operation time of 235 (190, 290) minutes and an estimated intraoperative blood loss of 200 (150, 400) ml. The resection margins were as follows: R0 in 95 cases (43.2%), R1\u0026thinsp;\u0026lt;\u0026thinsp;1mm in 88 cases (40.0%), and R1-direct in 14 cases (6.4%). The median postoperative hospital stay was 15 (12, 24) days.\u003c/p\u003e \u003cp\u003eThe interval from surgery to the initiation of AC was similar between the AC(d+) and AC(pr) groups (50 vs. 57 days, P\u0026thinsp;=\u0026thinsp;0.108), but significantly shorter in the AC(d+) group compared to the AC(d\u0026minus;) group (50 vs. 61 days, P\u0026thinsp;=\u0026thinsp;0.015). However, patients in the AC(d+) group had a longer interval from surgery to drainage removal compared to those in the AC(d\u0026minus;) group (89 vs. 42 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, a smaller proportion of patients in the AC(pr) group underwent distal pancreatectomy compared to those in the AC(d+) group. There were no statistically significant differences in other baseline characteristics, as demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics, Tumour Characteristics, Surgical-related Data of AC(d+) and AC(d-) Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAC(d+)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAC(d-)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAC(pr)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;136)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP- \u003cem\u003evalue\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(d\u0026thinsp;+\u0026thinsp;vs d-)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP-value (d\u0026thinsp;+\u0026thinsp;vs pr)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, \u003cem\u003em\u0026thinsp;\u0026plusmn;\u0026thinsp;sd\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative CA 19\u0026thinsp;\u0026minus;\u0026thinsp;9 (U/ml), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (47, 404)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (44, 473)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129 (53, 299)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation type, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e235 (186, 297)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240 (198, 296)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e230 (190, 289)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative blood loss (ml), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200 (100, 500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200 (100, 300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200 (150, 400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor grade differentiation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80 (58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e#\u003c/sup\u003eResection margins, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (51.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u0026thinsp;\u0026lt;\u0026thinsp;1mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1-direct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e#\u003c/sup\u003eT stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37(30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.791\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (41.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e#\u003c/sup\u003eAJCC 8th stage, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCauses of inability to remove drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOPF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (86.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (82.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay (d), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (13, 36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (11, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (12, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAC regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGemcitabine-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103 (75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFFX-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (19.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFFX-gemcitabine combination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG performance status at initiating AC, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (52.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval from surgery to drainage removal (d), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (68, 111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (33, 55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (8, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval from surgery to initiation of AC (d), \u003cem\u003eM(QR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (44, 65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (50, 78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (48, 66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted six cycles of AC, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eECOG, Eastern Cooperative Oncology Group; mFFX, mFOLFIRINOX; NA, Not Available; AC, Adjuvant Chemotherapy; \u003csup\u003e#\u003c/sup\u003eMissing data exist\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison of chemotherapy-related adverse reactions\u003c/h2\u003e \u003cp\u003eOf the 220 patients in the study, 107 (48.7%) experienced grade 3\u0026ndash;4 chemotherapy-related adverse events, with neutropenia being the most common, occurring in 64 patients (29.1%). Other grade 3\u0026ndash;4 adverse events included sensory peripheral neuropathy in 45 patients (20.1%), abdominal infection in 35 patients (15.9%), thrombocytopenia in 29 patients (13.2%), fatigue in 26 patients (11.8%), and anemia in 20 patients (9.1%).\u003c/p\u003e \u003cp\u003eNo significant differences in new-onset surgery-related complications, including hemorrhage, ileus, and abdominal infection, were observed between the AC(d+) group and either the AC(d\u0026minus;) or AC(pr) groups. Additionally, no significant differences were observed in the incidence of grade 3\u0026ndash;4 chemotherapy-related adverse events. A more detailed description of these adverse events is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Grade 3\u0026ndash;4 Chemotherapy-Related Adverse Events Among Different Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAC(d+) (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAC(d-) (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAC(pr) (n\u0026thinsp;=\u0026thinsp;136)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP-value (d\u0026thinsp;+\u0026thinsp;vs. d-)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP-value (d\u0026thinsp;+\u0026thinsp;vs. pr)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematologic event\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukopenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutropenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombocytopenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFebrile neutropenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNonhematologic event\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection of other sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.581\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensory peripheral neuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBiochemical event\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT/AST increased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP/γ-GGT increased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood total bilirubin increased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoalbuminemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine increased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPTT prolonged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eALT, alanine aminotrans-ferase level; AST, aspartate aminotrans-ferase level;ALP, alkaline phosphatase level; γ-GGT, γ-glutamyltransferase level. Activated partial thromboplastin time\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSurvival analysis\u003c/h2\u003e \u003cp\u003eIn June 2023, with a median follow-up duration of 17.0 (14.6, 19.4) months, 101 patients (45.9%) were observed to have local recurrence and/or distant metastasis, and the median RFS was 18.7 (95% CI, 15.3\u0026ndash;22.1) months. A total of 43 deaths (19.5%) were observed during the follow-up period, including eight patients in the AC(d\u0026minus;) group, eight patients in the AC(d+) group, and 27 patients in the AC(pr) group. The estimated 1-year and 2-year survival rates were 85.6% and 60.5%, respectively, for the AC(d\u0026minus;) group, and 95.8% and 61.0% for the AC(d+) group. In the AC(pr) group, the corresponding survival rates were 89.1% and 64.0%. The median OS endpoint has not been attained as of the current analysis.\u003c/p\u003e \u003cp\u003eCox univariate regression analysis revealed that the tumour grade differentiation, resection margins, AJCC 8th stage, the interval from surgery to the initiation of AC, and completed six cycles of chemotherapy were significantly associated with RFS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Cox multivariate regression analysis unveiled that tumour grade differentiation, completed six cycles of therapy, the interval from surgery to the initiation of AC and resection margins were independent factors affecting RFS. Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the RFS curves.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate Cox Proportional Hazards Models (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo. of Recurrence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian RFS Time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.5 (10.3\u0026ndash;24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9 (16.5\u0026ndash;21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.126 (0.757\u0026ndash;1.674)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative CA 19\u0026thinsp;\u0026minus;\u0026thinsp;9 (U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.2 (16.7\u0026ndash;25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1 (12.7\u0026ndash;19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.353 (0.908\u0026ndash;2.016)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eTumor grade differentiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.7 (12.5\u0026ndash;30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.2 (10.3\u0026ndash;18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.001 (1.294\u0026ndash;3.097)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e#\u003c/sup\u003eResection margins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.3 (18.0-28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u0026thinsp;\u0026lt;\u0026thinsp;1mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.0 (12.9\u0026ndash;29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.478 (0.922\u0026ndash;2.370)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1-direct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.9 (6.1\u0026ndash;13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.289 (1.660\u0026ndash;6.519)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e#\u003c/sup\u003eAJCC 8th stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.7 (9.7\u0026ndash;33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9 (13.3\u0026ndash;24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.433 (0.846\u0026ndash;2.424)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0 (10.2\u0026ndash;15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.321(1.280\u0026ndash;4.208)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG performance status at initiating AC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.4 (8.5\u0026ndash;36.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.2 (8.9\u0026ndash;40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.809 (0.404\u0026ndash;1.622)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.2 (6.3\u0026ndash;22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.363 (0.596\u0026ndash;3.118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAC regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGemcitabine-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.7 (16.3\u0026ndash;20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFFX-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0 (9.1\u0026ndash;40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.859 (0.508\u0026ndash;1.455)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFFX-gemcitabine combination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.1 (13.6\u0026ndash;14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.296 (0.596\u0026ndash;2.814)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAC (d+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.7 (15.7\u0026ndash;21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.2 (11.7\u0026ndash;34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.970 (0.567\u0026ndash;1.659)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.911\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval from surgery to drainage removal (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval from surgery to initiation of AC (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted six cycles of therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9 (2.5\u0026ndash;15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9 (15.5\u0026ndash;22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.415 (0.258\u0026ndash;0.668)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eECOG, Eastern Cooperative Oncology Group; mFFX, FOLFIRINOX; AC, Adjuvant Chemotherapy; \u003csup\u003e*\u003c/sup\u003eTwo well-differentiated tumors were excluded from analysis; \u003csup\u003e#\u003c/sup\u003eMissing data exist\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Cox Proportional Hazards Models (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eHR(95% CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval from surgery to initiation of AC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.012 (1.001\u0026ndash;1.023)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor grade differentiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.510 (1.481\u0026ndash;4.254)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResection margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.740 (1.235\u0026ndash;2.451)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAJCC 8th stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.356 (0.957\u0026ndash;1.922)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted six cycles of therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.771\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.443 (0.250\u0026ndash;0.785)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite a relatively high overall incidence of complications following pancreatic surgery, advances in the management and understanding of complications have led to significant decreases in mortality and reoperation rates,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e enabling the possibility of administering AC without the removal of intraperitoneal drainage. Our findings, for the first time, indicate that there was no increase in the incidence of grade 3\u0026ndash;4 adverse reactions and new-onset surgery-related complications associated with AC(d+) treatment. These preliminary results suggest that AC(d+) is a safe and feasible treatment approach for patients who are unable to remove intraperitoneal drainage following pancreatic cancer resection.\u003c/p\u003e \u003cp\u003eBefore proceeding with AC(d+), careful consideration ought to be given to two critical factors. Firstly, the patient\u0026rsquo;s physical and nutritional status should be assessed. Patients with a poor physical or nutritional status are typically advised to receive enteral nutrition either in the hospital or at home. Secondly, the possibility of obstructed abdominal fluid drainage should be ruled out, with imaging examinations serving as the primary method of assessment. In cases where fluid accumulation is detected around the drainage tube, it may be necessary to either replace the tube or withdraw it by 1\u0026ndash;2cm. Conversely, if the fluid accumulation is remote from the drainage tube, percutaneous puncture drainage may be considered.\u003c/p\u003e \u003cp\u003eThe incidence of granulocytopenia following AC for pancreatic cancer ranges from 23.0\u0026ndash;77.8%, with granulocyte deficiency occurring in approximately 5.4\u0026ndash;22.2% of cases.\u003csup\u003e\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e When combined with infection, this condition carries a high mortality rate. To prevent granulocyte deficiency in high-risk patients (e.g. those with low baseline white blood cell counts, liver dysfunction, or high ECOG scores) before AC(d+), proactive measures such as nutritional support and prophylactic use of G-CSF should be considered. In the case of granulocyte deficiency and infection, blood and drainage cultures for bacteria ought to be performed, followed by the administration of broad-spectrum antibiotics and G-CSF.\u003c/p\u003e \u003cp\u003eInterestingly, chemotherapy drugs have the potential to induce the degeneration of pancreatic cells, widespread lobular atrophy, tissue fibrosis, and diminished exocrine pancreatic function, which could potentially lead to a decrease in the secretion of pancreatic fluid.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This effect might well be influenced by the specific chemotherapy regimen. 5-Fu has demonstrated efficacy in treating acute pancreatitis and refractory pancreatic fistula,\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e whilst gemcitabine-based regimen do not have this effect. In this study, AC(d+) did not shorten the duration of drainage. The interval from surgery to drainage removal was significantly longer in the AC(d+) group compared to the AC(d\u0026minus;) group (89 days vs. 42 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The high proportion (70.2%) of gemcitabine-based regimens used in the AC(d+) group may have contributed to this finding. Further analysis revealed that in the AC(d+) group, the duration of drainage for patients receiving the mFOLFIRINOX-based regimen was notably shorter than for those receiving the gemcitabine-based regimen (55 days vs. 64 days, P\u0026thinsp;=\u0026thinsp;0.062), although this difference did not reach statistical significance. Additionally, existing literature suggests that chemotherapy may impair the healing of fistulas, which could be an important factor contributing to prolonged drainage time.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e To determine which factor plays a more significant role, additional large-scale controlled trials are needed to validate these findings.\u003c/p\u003e \u003cp\u003eIn the CONKO-001 study, chemotherapy was initiated between days 10 and 42 postoperatively.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Shortly thereafter, the ESPAC-3 and ESPAC-4 trials initiated chemotherapy within 12 weeks based on expert consensus.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Consequently, the NCCN guidelines suggest initiating AC within 12 weeks after adequate recovery from surgery.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, some patients may experience delayed initiation of AC beyond 12 weeks due to the inability to remove the abdominal drainage.\u003c/p\u003e \u003cp\u003eMoreover, despite current guidelines recommending AC initiation within 12 weeks after surgery, several studies have reported a poorer prognosis in patients with delayed initiation of AC within this timeframe.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Sung Jun et al.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e found that patients with stage I\u0026ndash;II pancreatic cancer who commenced adjuvant therapy 28\u0026ndash;59 days following primary surgical resection exhibited a superior 2-year survival rate (51.3% vs. 45.4%, P\u0026thinsp;=\u0026thinsp;0.01) and OS (22.4 vs. 20.4 months, P\u0026thinsp;=\u0026thinsp;0.01) in comparison with those who initiated adjuvant treatment before 28 days or after 59 days. In a study conducted by Richard et al.,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e propensity score matching analysis revealed a significant association between earlier delivery (\u0026lt;\u0026thinsp;66 days) of AC and improved survival in patients with stage I\u0026ndash;III pancreatic cancer. The 5-year survival rate was 20% in patients who received AC within 66 days in comparison to 18% in those who did not (P\u0026thinsp;=\u0026thinsp;0.0266).\u003c/p\u003e \u003cp\u003eFor patients with a high risk of recurrence, early administration of chemotherapy may offer potential survival benefits.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The data from the ESPAC-3 study indicated that the ability to complete six cycles of AC is an independent prognostic factor for survival in pancreatic cancer, which aligns with our findings. However, in that study, for patients unable to complete all six cycles of chemotherapy, the timing of chemotherapy initiation emerged as an independent factor influencing both disease-free survival (DFS) and overall survival (OS).\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Recent studies have also found that, for pancreatic cancer patients who are positive for postoperative circulating tumour cells, delaying chemotherapy significantly shortens the time to RFS (12.4 vs. 17.9 months, P\u0026thinsp;=\u0026thinsp;0.004).\u003csup\u003e5\u003c/sup\u003e Moreover, despite the controversy surrounding the issue, several studies have suggested that POPF is a significant risk factor for high recurrence rates in patients with pancreatic cancer.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e A meta-analysis conducted by Grego et al. (2021) reported a 59% increased risk of tumour recurrence in patients with pancreatic cancer who developed POPF.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Likewise, Nagai et al.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e discovered that pancreatic fistula after surgery was associated with a four times higher risk of peritoneal recurrence. Multivariate analysis in this study demonstrated that the interval from surgery to the initiation of AC is an independent factor affecting RFS. AC(d+) may be more warranted in this particular patient population.\u003c/p\u003e \u003cp\u003eAdditionally, Our study identified tumor differentiation and resection margin status as independent prognostic factors for survival, consistent with previous literature. Well-differentiated tumors typically indicate less aggressive biology and better outcomes, while negative resection margins reflect more complete tumor clearance and improved prognosis. Carlo Ingaldi et al. reported that well-differentiated tumors (G1), R0 resections, and adjuvant chemotherapy were all associated with longer survival (p\u0026thinsp;=\u0026thinsp;0.010, 0.019, and 0.052, respectively)..\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Similarly, Yamamoto et al. identified R0 resection as an independent favorable prognostic factor (HR\u0026thinsp;=\u0026thinsp;0.48; 95% CI: 0.30\u0026ndash;0.77; P\u0026thinsp;=\u0026thinsp;0.003).\u003csup\u003e33\u003c/sup\u003e Luu AM et al. also confirmed tumor grade as an independent predictor of survival in PDAC, underscoring its value in postoperative risk stratification.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere exist certain limitations in this study. Firstly, our study was constrained by a limited sample size and a retrospective design. Although the baseline characteristics of the two groups are comparable, there remains a potential for residual confounding. Secondly, our study preliminarily demonstrates the safety and feasibility of AC(d+), while analyzing the factors influencing RFS. However, a long-term survival analysis is still required, and extended follow-up is essential to ascertain enduring survival outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAdministering AC was safe for patients who underwent resection for PDAC and encountered challenges in the prompt removal of intraperitoneal drainage beyond 30 days post-surgery. The proactive management of preventing delays in chemotherapy administration could reduce the early recurrence risk in this particular patient cohort.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval \u003c/h2\u003e\n\u003cp\u003eEthics approval This study was approved by the Ethics Committee of the First Affiliated Hospital with Nanjing Medical University.\u003c/p\u003e\n\u003ch2\u003eConsent to participate \u003c/h2\u003e\n\u003cp\u003eAll patients signed an informed consent form.\u003c/p\u003e\n\u003ch2\u003eFunding \u003c/h2\u003e\n\u003cp\u003eThis study was supported by National Natural Science Foundation of China (No.82072706).\u003c/p\u003e\n\u003ch2\u003eCompeting interests \u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDong Xu designed the study, collected and analyzed the data, and drafted the manuscript. Min Tu and Nan Lv contributed to data collection and analysis. Qianqian Wang and Yang Wu assisted in data interpretation and manuscript revision. Kai Zhang provided statistical support and contributed to data analysis. Yi Miao participated in the study design and provided critical revisions. Jishu Wei , Min Tu and Kuirong Jiang, as corresponding authors, supervised the study, provided critical intellectual input, and revised the manuscript for important content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel RL, et al. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalbrook CJ, et al. Pancreatic cancer: Advances and challenges. Cell. 2023;186(8):1729\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarchegiani G, Bassi C. Prevention, prediction, and mitigation of postoperative pancreatic fistula. Br J Surg. 2021;108(6):602\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValle JW, et al. Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study. J Clin Oncol. 2014;32(6):504\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaved AA et al. \u003cem\u003eA Delay in Adjuvant Therapy is Associated with Worse Prognosis only in Patients with Transitional Circulating Tumor Cells Following Resection of Pancreatic Ductal Adenocarcinoma.\u003c/em\u003e Ann Surg, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonaroti JW, et al. Impact of postoperative pancreatic fistula on long-term oncologic outcomes after pancreatic resection. HPB (Oxford). 2021;23(8):1269\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eNational Comprehensive Cancer Network. (NCCN) Clinical Practice Guidelines in Oncology.Pancreatic Adenocarcinoma, Version 1.\u003c/em\u003e2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nccn.org/guidelines/guidelines-detail?category=1\u003c/span\u003e\u003cspan address=\"https://www.nccn.org/guidelines/guidelines-detail?category=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cem\u003e\u0026amp;id=1455. Accessed 15 April 2023. In.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBockhorn M, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2014;155(6):977\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKokkinakis S, et al. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int. 2022;21(6):527\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015;220(4):530\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIto G, et al. Risk factors for severe neutropenia in pancreatic cancer patients treated with gemcitabine/nab-paclitaxel combination therapy. PLoS ONE. 2021;16(7):e0254726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrisawa A, et al. Incidence of and risk factors for severe neutropenia during treatment with the modified FOLFIRINOX therapy in patients with advanced pancreatic cancer. Sci Rep. 2022;12(1):15574.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeum J, et al. Single-center risk factor analysis for FOLFIRINOX associated febrile neutropenia in patients with pancreatic cancer. Cancer Chemother Pharmacol. 2020;85(4):651\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaito Y, et al. Detection of risk factors related to administration suspension and severe neutropenia in gemcitabine and nab-paclitaxel treatment. Support Care Cancer. 2021;29(6):3277\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalimuthu SN, et al. The spectrum of histopathological changes encountered in pancreatectomy specimens after neoadjuvant chemoradiation, including subtle and less-well-recognised changes. J Clin Pathol. 2016;69(6):463\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHank T, et al. Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy. JAMA Surg. 2019;154(10):943\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahdaleh FS, et al. Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis. J Gastrointest Surg. 2021;25(3):747\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgescu T et al. \u003cem\u003e[5-fluorouracil treatment of acute pancreatitis and of pancreatic and duodenal fistulae].\u003c/em\u003e Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir, 1990. 39(1): pp. 45\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConstantinescu C, Puiu R, Straja D. \u003cem\u003e[5-Fluorouracil (ftorafur) in the treatment of acute pancreatitis. Indications for and efficacy of its use].\u003c/em\u003e Rev Med Interna Neurol Psihiatr Neurochir Dermatovenerol Med Interna, 1989. 41(5): pp. 443-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubyshkin VA, Chzhao AV, Chugunov AO. [5-fluorouracil in the treatment and prevention of acute pancreatitis]. Vestn Khir Im I I Grek. 1982;129(8):132\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlonimska P, et al. Chemotherapy-Mediated Complications of Wound Healing: An Understudied Side Effect. Adv Wound Care (New Rochelle). 2024;13(4):187\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOettle H, et al. Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA. 2013;310(14):1473\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeoptolemos JP, et al. Effect of adjuvant chemotherapy with fluorouracil plus folinic acid or gemcitabine vs observation on survival in patients with resected periampullary adenocarcinoma: the ESPAC-3 periampullary cancer randomized trial. JAMA. 2012;308(2):147\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeoptolemos JP, et al. Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet. 2017;389(10073):1011\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa SJ, et al. Association of Timing of Adjuvant Therapy With Survival in Patients With Resected Stage I to II Pancreatic Cancer. JAMA Netw Open. 2019;2(8):e199126.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite RJ, et al. Time to Adjuvant Systemic Therapy Following Pancreatic Cancer Resection and Effect on Outcome. Pancreas. 2019;48(8):1086\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeillette G, et al. Implications and management of pancreatic fistulas following pancreaticoduodenectomy: the Massachusetts General Hospital experience. Arch Surg. 2008;143(5):476\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagai S, et al. Recurrence pattern and prognosis of pancreatic cancer after pancreatic fistula. Ann Surg Oncol. 2011;18(8):2329\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrego A et al. \u003cem\u003eDoes Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis.\u003c/em\u003e Cancers (Basel), 2021. 13(22).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUchida Y, et al. Postoperative pancreatic fistulas decrease the survival of pancreatic cancer patients treated with surgery after neoadjuvant chemoradiotherapy: A retrospective analysis. Surg Oncol. 2020;35:527\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe Y, et al. Effect of postoperative major complications on prognosis after pancreatectomy for pancreatic cancer: a retrospective review. Surg Today. 2017;47(5):555\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIngaldi C, et al. Clinicopathological predictive factors in long-term survivors who underwent surgery for pancreatic ductal adenocarcinoma: A single-center propensity score matched analysis. World J Surg. 2024;48(12):3001\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto T, et al. Long-term survival after resection of pancreatic cancer: a single-center retrospective analysis. World J Gastroenterol. 2015;21(1):262\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuu AM, et al. Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int. 2021;20(3):271\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pancreatic cancer, Postoperative pancreatic fistula, Intraperitoneal drainage, Adjuvant chemotherapy, Recurrence-free Survival","lastPublishedDoi":"10.21203/rs.3.rs-6003455/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6003455/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePancreatectomy remains associated with a high incidence of complications. In certain cases, patients with pancreatic ductal adenocarcinoma (PDAC) face challenges in removing intraperitoneal drainage after surgery, leading to potential delays in the administration of adjuvant chemotherapy (AC) and potentially impacting survival outcomes. The objective of this study was to evaluate the feasibility and potential benefits of AC in PDAC patients who are unable to remove intraperitoneal drainage over 30 days.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBetween January 2021 and December 2022, a total of 220 patients with resected PDAC received AC at our center. Among them, 84 patients experienced persistent intraperitoneal drainage lasting more than 30 days postoperatively. Of these, 38 patients (45.2%) initiated AC despite the ongoing presence of drainage and were classified as the AC(d+) group, while the remaining 46 patients (54.8%) began AC only after successful drainage removal, and were categorized as the AC(d\u0026minus;) group. The other 136 patients, who underwent prompt removal of intraperitoneal drainage, were assigned to the AC(pr) group. Baseline information, surgery-related outcomes, and chemotherapy-related adverse events were collected and compared between the two groups, and factors that affected recurrence-free survival (RFS) were also analysed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOf the 220 patients included in the study, 107 (48.7%) experienced grade 3\u0026ndash;4 chemotherapy-related adverse events. The interval from surgery to the initiation of AC was similar between the AC(d+) and AC(pr) groups (50 vs. 57 days, P\u0026thinsp;=\u0026thinsp;0.108). However, it was significantly shorter in the AC(d+) group compared to the AC(d\u0026minus;) group (50 vs. 61 days, P\u0026thinsp;=\u0026thinsp;0.015). Notably, no additional chemotherapy-related adverse events were observed in the AC(d+) group compared to either the AC(d\u0026minus;) or AC(pr) groups. The estimated 1-year and 2-year survival rates were 85.6% and 60.5%, respectively, for the AC(d\u0026minus;) group, and 95.8% and 61.0% for the AC(d+) group. In the AC(pr) group, the corresponding survival rates were 89.1% and 64.0%. Cox multivariate regression analysis demonstrated that tumour grade differentiation, completed six cycles of therapy, the interval from surgery to the initiation of AC and resection margins were independent factors affecting RFS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAdministering AC was safe for patients who underwent resection for PDAC and encountered challenges in the prompt removal of intraperitoneal drainage beyond 30 days post-surgery. The proactive management of preventing delays in chemotherapy administration could reduce the early recurrence risk in this particular patient cohort.\u003c/p\u003e","manuscriptTitle":"The feasibility and potential benefits of administering adjuvant chemotherapy in resected pancreatic cancer patients unable to promptly remove intraperitoneal drainage post-surgery: A retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 23:06:41","doi":"10.21203/rs.3.rs-6003455/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-05-02T14:36:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T08:48:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-29T20:40:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66779498287623795430275139426615132913","date":"2025-04-14T12:00:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179770772222196134483414768291665102665","date":"2025-04-12T07:42:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-10T07:41:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-09T02:05:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-04-08T11:53:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2757c21-3bbf-4edd-a4c9-dfd2d69aaaa4","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:05:23+00:00","versionOfRecord":{"articleIdentity":"rs-6003455","link":"https://doi.org/10.1186/s12885-025-14262-1","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-05-20 15:58:42","publishedOnDateReadable":"May 20th, 2025"},"versionCreatedAt":"2025-04-14 23:06:41","video":"","vorDoi":"10.1186/s12885-025-14262-1","vorDoiUrl":"https://doi.org/10.1186/s12885-025-14262-1","workflowStages":[]},"version":"v1","identity":"rs-6003455","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6003455","identity":"rs-6003455","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}