[Surgical technique and outcome in pancreatic carcinoma]

Surgical treatment of ductal adenocarcinoma of the pancreas is considerably influenced by the delicate retroperitoneal position of the gland with close contact to major mesenteric vessels, lymphatics and nerve structures as well as by the unfavourable tumor biology including high affinity towards nerve tissue and early systemic spread. Based on these preconditions, kind and extent of resective measures have to be discussed with special care. Total pancreatectomy to improve radicality has been abandoned because of exaggerated early and late mortality and morbidity. The principle of distal gastric resection as part of the classic Whipple operation was shown to be oncologically not effective. It seems to be justified only if the tumor reaches the duodenopancreatic angle. Resection of the mesenteric vein is technically feasible with acceptable mortality, but leads to unfavourable survival rates since the respective lesions mostly are in an advanced stage. Extensive tissue clearance around the mesenteric vessels did not improve survival, but led to intractable diarrhoea in up to 76% of the cases. Concerning 114 patients resected for pancreatic head cancer in the own department actuarial 5-year survival was 6%. There was no significant difference whether classic Whipple (3%) or pylorus preservation (8%) was applied. None of the node positive patients survived more than 4 years. In contrast, those with negative nodes achieved 29% 5-years survival (p = 0.0059). Following 26 resections of the left pancreas for ductal carcinoma non of the patients survived more than 2 years. Results of the recent literature and the own experience are suggestive to believe that node positive stages won't benefit from extensive surgery. Therefore anatomical resection including the peripancreatic lymph node compartment is sufficient to preserve the chance for cure in early stages. Nowadays preservation of the stomach is the standard technique during pancreatoduodenectomy, which is, provided a perioperative mortality of less than 5%, accepted also as best palliation in suitable patient of advanced stages.