Surgical options in the management of pancreatic cancer

Management of pancreatic cancer is an interdisciplinary challenge as this tumor entity is still characterized by a poor prognosis and an overall long-term survival of only 1-5%. From the oncological dimension, pancreatic cancer represents the fourth leading cause of cancer related mortality in the Western world with more than 100000 deaths in Europe and the USA per year. A major problem is the early detection since 80-90% of pancreatic cancers are locally or systemically advanced at the time of diagnosis. However, in patients who are suitable for resection five-year survival rates of about 25% are observed, which underlines that surgery offers the only chance of potential cure and long-term survival. Yet, surgical therapy has to be embedded in an oncological concept of adjuvant treatment as postoperative chemotherapy is a key factor to further improve patient survival. Numerous ongoing studies on new therapeutic agents like antibodies, antimetabolites and supportive agents reflect the current scientific and clinical struggle to achieve better outcome of pancreatic cancer patients in the future on the basis of initial tumor resection or if this is not possible as a palliative treatment. Standard resections include partial pancreatico-duodenectomy with distal gastric resection or recently accepted as the preferable procedure preservation of the pylorus for tumors in the head of the pancreas, distal pancreatectomy for tumors of the corpus and tail as well as total pancreatectomy for more extended tumors or intraductal papillary mucinous neoplasias if necessary. Venous resections including the portal and superior mesenteric vein during these procedures are well-accepted, while resection of arterial vessels, metastases or recurrent disease are not considered as standard procedures and should therefore only be performed for special indications and in selected patients. Today, standardization of surgical procedures and centralization of pancreatic surgery in high volume institutions guarantees best patient care and mortality rates below 5%.