Surgery for advanced and metastatic pancreatic cancer--current state and trends

Due to the late onset of symptoms in pancreatic cancer, patients are often presented with an already advanced or metastatic state of disease. Only in a minority of patients is a tumor resection indicated, e.g. in general tumor encasement of major vessels, while the presence of metastatic disease excludes patients from curative-intended surgery. Limitations for pancreatic resections have been debated and re-thought after more experience has gained over time. This holds true for en-bloc vascular resections, total pancreatectomies, intentional R2 pancreatic resections and synchronous resection of liver metastases. These issues are addressed in this review.