Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

Abstract

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics.:

PADULAP study: To compare postoperative and pathologic results between open and laparoscopic approach for pancreaticoduodenectomy

“…La DPC es la técnica quirúrgica de elección para el tratamiento radical de las neoplasias ubicadas en el duodeno, región periampular, confluente bilio-pancreático y cabeza del páncreas (1)(2)(3). Aunque su indicación por lo general es en patología maligna, también puede ser el tratamiento de elección para algunas enfermedades benignas como la pancreatitis crónica, la distrofia quística de la pared duodenal, etc.…”

“…Aunque se trata de una intervención quirúrgica muy contrastada, generalizada y ampliamente utilizada, sigue siendo una intervención de alta complejidad técnica y con un elevado riesgo de complicaciones postoperatorias y mortalidad, incluso cuando se realiza en centros de alto volumen y excelencia (1,(5)(6)(7)(8)(9)(10). La fístula pancrática es la complicación específica más importante de esta intervención puesto que de ella suelen derivar otro tipo de complicaciones como la gastroparesia, el íleo paralítico, los abscesos intraabdominales, las sepsis graves y las hemorragias intra y/o extraluminales (8).…”

Neoadjuvant chemotherapy for pancreatic cancer: Effects on cancer tissue and novel perspectives

“…Neoadjuvant treatment is often considered separately from resectable pancreatic cancer and BRPC and/or LAPC. Furthermore, patients with BRPC and LAPC have ~50% chance of curative resection compared with patients with resectable pancreatic cancer (26)(27)(28)(29).…”

Robotic‐assisted pancreatic surgery

“…Total pancreatectomy (TP) is a technically demanding procedure required in selected cases where chronic pancreatitis, multifocal neuroendocrine tumours or diffuse intraductal papillary mucinous neoplasm are present [38,39]. For malignant cases, it is warranted when multiple foci of adenocarcinoma are detected.…”