The Progress of Pancreatectomy for Pancreatic Cancer Treatment-Lessons Learned and Future Challenges

Since decades, surgery of pancreatic adenocarcinoma is confronted with two major challenges. First, the prognosis of pancreatic adenocarcinoma is the worst of all gastrointestinal malignancies, characterized by late diagnosis and aggressive tumor biology. Second, postoperative mortality and morbidity have been exceptionally high, giving pancreatic resection a reputation of being one of the most dangerous procedures. This narrative review concentrates on the progress in decreasing postoperative mortality by centralization and standardization, the exertion of extended resections for local tumor clearance and multimodal strategies to improve oncologic survival. Research regarding surgical techniques, especially robotic assistance, indicated further progress in minimizing the perioperative trauma. Multimodal treatment concepts have been implemented with adjuvant therapy in resectable and neoadjuvant regimen in borderline and locally advanced cancer. However, significant problems have to be solved. Postoperative morbidity remains high, hindering the administration of adjuvant therapy, and toxicity is an essential factor in neoadjuvant strategies. Despite neoadjuvant therapies, resection rates of locally advanced carcinoma are modest and tumor progression hinders resection of borderline and resectable carcinomas. Obviously, deficits in understanding tumor biology are a central obstacle in improving resection rates and overall survival. Hence, improvement in selection of patients for surgical resection apart from using preoperative anatomical findings is mandatory. The progression of current standards, future developments and the status of surgery in multimodal concepts to treat pancreatic adenocarcinoma are delineated using historical and recent reports, registry data, meta-analysis and randomized controlled trials.