Pancreatoduodenectomy for Gastric Cancer With Pancreatic Involvement: Indications, Outcomes, and Prognostic Factors

Pancreatoduodenectomy (PD) is rarely indicated for gastric cancer because of its high morbidity and uncertain survival benefit; however, in selected patients with gastric cancer and pancreatic involvement, PD may be required to achieve complete oncologic resection. This narrative review summarizes current evidence regarding indications, outcomes, and prognostic factors associated with PD in gastric cancer with pancreatic invasion. A narrative review of the literature was conducted focusing on published series evaluating clinicopathologic features, surgical management, perioperative outcomes, survival, and prognostic factors in patients undergoing PD for gastric cancer with pancreatic involvement. Pancreatic involvement is an uncommon finding in gastric cancer; however, PD is considered only in carefully selected patients when direct pancreatic invasion precludes margin-negative resection with standard gastrectomy. Tumors are most frequently located in the distal stomach and gastric antrum and are typically associated with advanced local disease. Preoperative imaging and intraoperative assessment have limited accuracy in distinguishing true pancreatic invasion from inflammatory adhesions, making histopathologic confirmation essential. Across published series, R0 resection can be achieved in a substantial proportion of patients; however, postoperative morbidity remains considerable, with pancreatic fistula being the most commonly reported complication. Long-term survival outcomes are highly variable and appear to be primarily influenced by tumor biology and the achievement of margin-negative resection. Consistently, the achievement of R0 resection emerges as the most important favorable prognostic factor. PD should not be routinely performed for gastric cancer but may be justified in carefully selected patients with pancreatic invasion when required to achieve complete oncologic resection, with outcomes driven more by oncologic factors than by the extent of surgery itself.