Surgery for pancreatic cancer: current controversies and challenges

Abstract

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Postoperative complications and short-term prognosis of laparoscopic pancreaticoduodenectomy vs. open pancreaticoduodenectomy for treating pancreatic ductal adenocarcinoma: a retrospective cohort study

“…Additionally, there are other modified techniques for reconstruction, such as using the falciform ligament, parietal peritoneum, and teres ligament, which means further potential applications of laparoscopic technique should be studied [ 1 ]. For surgeons, laparoscopic combined vascular resection and reconstruction are also feasible; however, they should be performed by an expert with outstanding skills in minimally invasive surgical techniques [ 35 ].…”

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

“… 87 Reported cases of RPD tripled from around 150 a year in 2010 to around 450 in 2016, 87 but its use remains low (less than 5% of PD performed in USA) because of its complexity. 88 The main, commonly-recognized benefits of MIPS 87 , 89 - 95 over open surgery (OPS) are less blood loss during the procedure and a shorter hospital stay, but the operating time is reportedly longer. 87 , 89 - 96 The number of lymph nodes removed with MIPS is much the same as with OPS, 87 , 92 , 93 , 95 or even higher.…”

“… 88 The main, commonly-recognized benefits of MIPS 87 , 89 - 95 over open surgery (OPS) are less blood loss during the procedure and a shorter hospital stay, but the operating time is reportedly longer. 87 , 89 - 96 The number of lymph nodes removed with MIPS is much the same as with OPS, 87 , 92 , 93 , 95 or even higher. 90 , 96 Similar complication, 87 , 90 - 95 reoperation, 87 , 91 , 93 - 95 unplanned readmission, 87 , 92 , 96 and mortality 87 , 90 - 96 rates are reported for OPS and MIPS.…”

“… 89 In other words, providing it is done at high-volume centers, MIPS is usually considered as safe as OPS for resectable PDAC, with some advantages in perioperative outcomes. 90 - 92 , 94 , 97 The complexity of MIPS makes it technically demanding, however.…”

“…One of the reported benefits of laparoscopic resections of the colon and esophagus, compared with open surgery, is a reduced inflammatory response (judging from the postoperative levels of inflammatory markers IL-6, IL-8 and CRP). 94 Unfortunately, this is not the case when LPD is compared with open PD. This supports the argument that the approach alone (ie MIPS) is not enough to alleviate the stress of PD or - rather more perilously - the procedure-related complications of LPD may even exacerbate the surgical stress.…”