Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of “art” and “science”

Abstract

Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long‐term survival outcomes, and various challenges in obtaining high‐level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long‐term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high‐level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico‐enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called “art” when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered “surgical artists,” “surgical scientists,” and “surgical practitioners.” We look forward to more “surgical artists” educating future “surgical artists and scientists” to create a richer “spirit of innovation,” leading to a more beautiful integration of art and science in the field of pancreatic surgery.

Adjuvant 5‐fluorouracil and portal vein infusion chemotherapy followed by gemcitabine for pancreatic cancer

“…Between November 2010 and August 2013, 70 patients from eight participating hospitals were enrolled in this trial. The inclusion criteria for the initial registration were as follows: (1) newly diagnosed PDAC and no previous antitumor treatment (e.g., chemotherapy, radiotherapy) except for biliary drainage; (2) age 20-86 years; (3) Eastern Cooperative Oncology Group performance status of 0-1; (4) adequate hematologic, hepatic, renal, and cardiopulmonary function; (5) no distant metastases; and (6) written informed consent. The inclusion criteria for subsequent registration after curative pancreatectomy for PDAC were In total, 51 (96.2%) patients underwent R0 resection, of whom 3, 2, 12, 35, 0, and 1 had stages IA, IB, IIA, IIB, III, and IV cancer, respectively, and 47 (88.7%) patients completed PI4W.…”

“…1,3 Recently, advancements in postoperative chemotherapy as an adjuvant treatment for pancreatic cancer have led to notable improvements in the 5-year survival rate. 4,5 In 2004, findings from the European Study Group for Pancreatic Cancer (ESPAC)-1 trial reported that adjuvant chemotherapy with fluorouracil (FU) and folinic acid showed notable survival advantage among patients who underwent resection for pancreatic cancer. 6 In 2007, the Charité Onkologie (CONKO)-001 trial reported that adjuvant chemotherapy utilizing gemcitabine (GEM) resulted in delayed recurrence and enhanced overall survival (OS) compared to surgery alone.…”

“…Even with complete curative resection, the 5‐year survival rate of patients with PDAC remains poor relative to other malignancies 1,3 . Recently, advancements in postoperative chemotherapy as an adjuvant treatment for pancreatic cancer have led to notable improvements in the 5‐year survival rate 4,5 . In 2004, findings from the European Study Group for Pancreatic Cancer (ESPAC)‐1 trial reported that adjuvant chemotherapy with fluorouracil (FU) and folinic acid showed notable survival advantage among patients who underwent resection for pancreatic cancer 6 .…”

Nutritional Support in Pancreatic Diseases

“…PC is often diagnosed in advanced stages. Only 20–30% of patients at the point of diagnosis are candidates for pancreatectomy [ 115 ]. The pancreas is a difficult-to-access organ to perform surgery on, due to its localization.…”

“…Late surgical morbidities include exocrine, endocrine pancreatic insufficiency and afferent loop syndrome. Both of these can cause nutritional disorders: the former after the surgery, and the latter in the long-term [ 115 ].…”