Surgical palliation for pancreatic cancer: developments during the past two decades

Improvements in pancreatic imaging over the past 20 years have revolutionized the preoperative diagnosis and assessment of resectability in patients with suspected pancreatic cancer. This review highlights the resultant trends in the surgical treatment of ductal carcinoma of the pancreas, comparing series reported between 1981 and 1990 with those from the previous decade. Small but worthwhile gains have been achieved both in overall resection rate and in the survival rate from such resections. Nevertheless, 80 per cent or more of affected patients are still unsuitable for resection because of the extent of their disease. Laparotomy retains a crucial role in the management of carcinoma of the pancreatic head, although percutaneous and endoscopic stents provide a useful alternative for palliation of malignant obstructive jaundice in elderly patients or those with carcinomatosis. Operation provides the chance to confirm the nature and full extent of the tumour, to circumvent duodenal obstruction and to abolish pain, besides relieving jaundice without the need for tubes (with their potential to block). By contrast, operative treatment generally has much less to offer in patients with carcinoma of the pancreatic body, unless diagnosis and irresectability remain in doubt. In combination, radiotherapy and 5-fluorouracil may achieve more as adjuncts to palliative surgery than either agent alone. The increasing safety of pancreaticoduodenectomy raises the possibility of palliative resection in younger patients with limited but incurable disease.