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Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.<ref name="pmid9635805">{{cite journal |vauthors=Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB |title=Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head |journal=Br J Surg |volume=85 |issue=5 |pages=611–7 |year=1998 |pmid=9635805 |doi=10.1046/j.1365-2168.1998.00641.x |url=}}</ref><ref name="pmid8597509">{{cite journal |vauthors=Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB |title=Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group |journal=Ann. Surg. |volume=223 |issue=2 |pages=154–62 |year=1996 |pmid=8597509 |pmc=1235091 |doi= |url=}}</ref><ref name="pmid22886567">{{cite journal |vauthors=Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T |title=Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma |journal=J Surg Oncol |volume=107 |issue=4 |pages=414–21 |year=2013 |pmid=22886567 |doi=10.1002/jso.23229 |url=}}</ref><ref name="pmid19156463">{{cite journal |vauthors=Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M |title=Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? |journal=Ann. Surg. Oncol. |volume=16 |issue=4 |pages=817–25 |year=2009 |pmid=19156463 |doi=10.1245/s10434-008-0281-8 |url=}}</ref> However, the involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>
Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.<ref name="pmid9635805">{{cite journal |vauthors=Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB |title=Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head |journal=Br J Surg |volume=85 |issue=5 |pages=611–7 |year=1998 |pmid=9635805 |doi=10.1046/j.1365-2168.1998.00641.x |url=}}</ref><ref name="pmid8597509">{{cite journal |vauthors=Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB |title=Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group |journal=Ann. Surg. |volume=223 |issue=2 |pages=154–62 |year=1996 |pmid=8597509 |pmc=1235091 |doi= |url=}}</ref><ref name="pmid22886567">{{cite journal |vauthors=Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T |title=Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma |journal=J Surg Oncol |volume=107 |issue=4 |pages=414–21 |year=2013 |pmid=22886567 |doi=10.1002/jso.23229 |url=}}</ref><ref name="pmid19156463">{{cite journal |vauthors=Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M |title=Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? |journal=Ann. Surg. Oncol. |volume=16 |issue=4 |pages=817–25 |year=2009 |pmid=19156463 |doi=10.1245/s10434-008-0281-8 |url=}}</ref> However, the involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>
Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision.
Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision.
The method of surgical resection depends on the following features:<ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref>
The method of surgical resection depends on the following features:<ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid27163957">{{cite journal |vauthors=Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M |title=Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma |journal=Ann. Surg. |volume=265 |issue=1 |pages=185–191 |year=2017 |pmid=27163957 |doi=10.1097/SLA.0000000000001763 |url=}}</ref><ref name="pmid17580363">{{cite journal |vauthors=Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS |title=Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database |journal=Cancer |volume=110 |issue=4 |pages=738–44 |year=2007 |pmid=17580363 |doi=10.1002/cncr.22852 |url=}}</ref><ref name="pmid27163957">{{cite journal |vauthors=Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M |title=Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma |journal=Ann. Surg. |volume=265 |issue=1 |pages=185–191 |year=2017 |pmid=27163957 |doi=10.1097/SLA.0000000000001763 |url=}}</ref>
*Locally invasive characteristics of the neoplasm
*Locally invasive characteristics of the neoplasm
*Size
*Size
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SURGERY
SURGERY
There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: <ref name="pmid12972517">{{cite journal |vauthors=Krzyzanowska MK, Weeks JC, Earle CC |title=Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness |journal=J. Clin. Oncol. |volume=21 |issue=18 |pages=3409–14 |year=2003 |pmid=12972517 |doi=10.1200/JCO.2003.03.007 |url=}}</ref><ref name="pmid16955382">{{cite journal |vauthors=Massucco P, Capussotti L, Magnino A, Sperti E, Gatti M, Muratore A, Sgotto E, Gabriele P, Aglietta M |title=Pancreatic resections after chemoradiotherapy for locally advanced ductal adenocarcinoma: analysis of perioperative outcome and survival |journal=Ann. Surg. Oncol. |volume=13 |issue=9 |pages=1201–8 |year=2006 |pmid=16955382 |doi=10.1245/s10434-006-9032-x |url=}}</ref><ref name="pmid12576921">{{cite journal |vauthors=Aristu J, Cañón R, Pardo F, Martínez-Monge R, Martin-Algarra S, Manuel Ordoñez J, Villafranca E, Moreno M, Cambeiro M, Azinovic I |title=Surgical resection after preoperative chemoradiotherapy benefits selected patients with unresectable pancreatic cancer |journal=Am. J. Clin. Oncol. |volume=26 |issue=1 |pages=30–6 |year=2003 |pmid=12576921 |doi= |url=}}</ref><ref name="pmid19576722">{{cite journal |vauthors=Turrini O, Viret F, Moureau-Zabotto L, Guiramand J, Moutardier V, Lelong B, Giovannini M, Delpero JR |title=Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma |journal=Eur J Surg Oncol |volume=35 |issue=12 |pages=1306–11 |year=2009 |pmid=19576722 |doi=10.1016/j.ejso.2009.06.005 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid28398845">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update |journal=J. Clin. Oncol. |volume=35 |issue=20 |pages=2324–2328 |year=2017 |pmid=28398845 |doi=10.1200/JCO.2017.72.4948 |url=}}</ref><ref name="pmid22569924">{{cite journal |vauthors=Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA |title='Artery-first' approaches to pancreatoduodenectomy |journal=Br J Surg |volume=99 |issue=8 |pages=1027–35 |year=2012 |pmid=22569924 |doi=10.1002/bjs.8763 |url=}}</ref><ref name="pmid24578248">{{cite journal |vauthors=Gurusamy KS, Kumar S, Davidson BR, Fusai G |title=Resection versus other treatments for locally advanced pancreatic cancer |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD010244 |year=2014 |pmid=24578248 |doi=10.1002/14651858.CD010244.pub2 |url=}}</ref><ref name="pmid18958561">{{cite journal |vauthors=Doi R, Imamura M, Hosotani R, Imaizumi T, Hatori T, Takasaki K, Funakoshi A, Wakasugi H, Asano T, Hishinuma S, Ogata Y, Sunamura M, Yamaguchi K, Tanaka M, Takao S, Aikou T, Hirata K, Maguchi H, Aiura K, Aoki T, Kakita A, Sasaki M, Ozaki M, Matsusue S, Higashide S, Noda H, Ikeda S, Maetani S, Yoshida S |title=Surgery versus radiochemotherapy for resectable locally invasive pancreatic cancer: final results of a randomized multi-institutional trial |journal=Surg. Today |volume=38 |issue=11 |pages=1021–8 |year=2008 |pmid=18958561 |doi=10.1007/s00595-007-3745-8 |url=}}</ref><ref name="pmid15086174">{{cite journal |vauthors=Lygidakis NJ, Singh G, Bardaxoglou E, Dedemadi G, Sgourakis G, Nestoridis J, Malliotakis A, Pedonomou M, Solomou EK, Safioleas M, Alamani M, Grigorakos L, Merikas EM |title=Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study |journal=Hepatogastroenterology |volume=51 |issue=56 |pages=427–33 |year=2004 |pmid=15086174 |doi= |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid8597508">{{cite journal |vauthors=Fortner JG, Klimstra DS, Senie RT, Maclean BJ |title=Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy |journal=Ann. Surg. |volume=223 |issue=2 |pages=147–53 |year=1996 |pmid=8597508 |pmc=1235090 |doi= |url=}}</ref><ref name="pmid2910241">{{cite journal |vauthors=Sindelar WF |title=Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=124 |issue=1 |pages=127–32 |year=1989 |pmid=2910241 |doi= |url=}}</ref><ref name="pmid6712317">{{cite journal |vauthors=Fortner JG |title=Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results |journal=Ann. Surg. |volume=199 |issue=4 |pages=418–25 |year=1984 |pmid=6712317 |pmc=1353360 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid24912627">{{cite journal |vauthors=Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, Zhao H, Wen J, Du Y, Lau WY, Zhang Y |title=Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=World J Surg |volume=38 |issue=10 |pages=2708–15 |year=2014 |pmid=24912627 |doi=10.1007/s00268-014-2633-9 |url=}}</ref><ref name="pmid10399969">{{cite journal |vauthors=Millikan KW, Deziel DJ, Silverstein JC, Kanjo TM, Christein JD, Doolas A, Prinz RA |title=Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas |journal=Am Surg |volume=65 |issue=7 |pages=618–23; discussion 623–4 |year=1999 |pmid=10399969 |doi= |url=}}</ref><ref name="pmid11296108">{{cite journal |vauthors=Balcom JH, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C |title=Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization |journal=Arch Surg |volume=136 |issue=4 |pages=391–8 |year=2001 |pmid=11296108 |doi= |url=}}</ref>
There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: <ref name="pmid12972517">{{cite journal |vauthors=Krzyzanowska MK, Weeks JC, Earle CC |title=Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness |journal=J. Clin. Oncol. |volume=21 |issue=18 |pages=3409–14 |year=2003 |pmid=12972517 |doi=10.1200/JCO.2003.03.007 |url=}}</ref><ref name="pmid16955382">{{cite journal |vauthors=Massucco P, Capussotti L, Magnino A, Sperti E, Gatti M, Muratore A, Sgotto E, Gabriele P, Aglietta M |title=Pancreatic resections after chemoradiotherapy for locally advanced ductal adenocarcinoma: analysis of perioperative outcome and survival |journal=Ann. Surg. Oncol. |volume=13 |issue=9 |pages=1201–8 |year=2006 |pmid=16955382 |doi=10.1245/s10434-006-9032-x |url=}}</ref><ref name="pmid12576921">{{cite journal |vauthors=Aristu J, Cañón R, Pardo F, Martínez-Monge R, Martin-Algarra S, Manuel Ordoñez J, Villafranca E, Moreno M, Cambeiro M, Azinovic I |title=Surgical resection after preoperative chemoradiotherapy benefits selected patients with unresectable pancreatic cancer |journal=Am. J. Clin. Oncol. |volume=26 |issue=1 |pages=30–6 |year=2003 |pmid=12576921 |doi= |url=}}</ref><ref name="pmid19576722">{{cite journal |vauthors=Turrini O, Viret F, Moureau-Zabotto L, Guiramand J, Moutardier V, Lelong B, Giovannini M, Delpero JR |title=Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma |journal=Eur J Surg Oncol |volume=35 |issue=12 |pages=1306–11 |year=2009 |pmid=19576722 |doi=10.1016/j.ejso.2009.06.005 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid28398845">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update |journal=J. Clin. Oncol. |volume=35 |issue=20 |pages=2324–2328 |year=2017 |pmid=28398845 |doi=10.1200/JCO.2017.72.4948 |url=}}</ref><ref name="pmid22569924">{{cite journal |vauthors=Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA |title='Artery-first' approaches to pancreatoduodenectomy |journal=Br J Surg |volume=99 |issue=8 |pages=1027–35 |year=2012 |pmid=22569924 |doi=10.1002/bjs.8763 |url=}}</ref><ref name="pmid24578248">{{cite journal |vauthors=Gurusamy KS, Kumar S, Davidson BR, Fusai G |title=Resection versus other treatments for locally advanced pancreatic cancer |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD010244 |year=2014 |pmid=24578248 |doi=10.1002/14651858.CD010244.pub2 |url=}}</ref><ref name="pmid18958561">{{cite journal |vauthors=Doi R, Imamura M, Hosotani R, Imaizumi T, Hatori T, Takasaki K, Funakoshi A, Wakasugi H, Asano T, Hishinuma S, Ogata Y, Sunamura M, Yamaguchi K, Tanaka M, Takao S, Aikou T, Hirata K, Maguchi H, Aiura K, Aoki T, Kakita A, Sasaki M, Ozaki M, Matsusue S, Higashide S, Noda H, Ikeda S, Maetani S, Yoshida S |title=Surgery versus radiochemotherapy for resectable locally invasive pancreatic cancer: final results of a randomized multi-institutional trial |journal=Surg. Today |volume=38 |issue=11 |pages=1021–8 |year=2008 |pmid=18958561 |doi=10.1007/s00595-007-3745-8 |url=}}</ref><ref name="pmid15086174">{{cite journal |vauthors=Lygidakis NJ, Singh G, Bardaxoglou E, Dedemadi G, Sgourakis G, Nestoridis J, Malliotakis A, Pedonomou M, Solomou EK, Safioleas M, Alamani M, Grigorakos L, Merikas EM |title=Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study |journal=Hepatogastroenterology |volume=51 |issue=56 |pages=427–33 |year=2004 |pmid=15086174 |doi= |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid8597508">{{cite journal |vauthors=Fortner JG, Klimstra DS, Senie RT, Maclean BJ |title=Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy |journal=Ann. Surg. |volume=223 |issue=2 |pages=147–53 |year=1996 |pmid=8597508 |pmc=1235090 |doi= |url=}}</ref><ref name="pmid2910241">{{cite journal |vauthors=Sindelar WF |title=Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=124 |issue=1 |pages=127–32 |year=1989 |pmid=2910241 |doi= |url=}}</ref><ref name="pmid6712317">{{cite journal |vauthors=Fortner JG |title=Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results |journal=Ann. Surg. |volume=199 |issue=4 |pages=418–25 |year=1984 |pmid=6712317 |pmc=1353360 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid24912627">{{cite journal |vauthors=Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, Zhao H, Wen J, Du Y, Lau WY, Zhang Y |title=Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=World J Surg |volume=38 |issue=10 |pages=2708–15 |year=2014 |pmid=24912627 |doi=10.1007/s00268-014-2633-9 |url=}}</ref><ref name="pmid10399969">{{cite journal |vauthors=Millikan KW, Deziel DJ, Silverstein JC, Kanjo TM, Christein JD, Doolas A, Prinz RA |title=Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas |journal=Am Surg |volume=65 |issue=7 |pages=618–23; discussion 623–4 |year=1999 |pmid=10399969 |doi= |url=}}</ref><ref name="pmid11296108">{{cite journal |vauthors=Balcom JH, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C |title=Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization |journal=Arch Surg |volume=136 |issue=4 |pages=391–8 |year=2001 |pmid=11296108 |doi= |url=}}</ref><ref name="pmid25348784">{{cite journal |vauthors=Serrano PE, Cleary SP, Dhani N, Kim PT, Greig PD, Leung K, Moulton CA, Gallinger S, Wei AC |title=Improved long-term outcomes after resection of pancreatic adenocarcinoma: a comparison between two time periods |journal=Ann. Surg. Oncol. |volume=22 |issue=4 |pages=1160–7 |year=2015 |pmid=25348784 |doi=10.1245/s10434-014-4196-2 |url=}}</ref><ref name="pmid21935914">{{cite journal |vauthors=Mayo SC, Nathan H, Cameron JL, Olino K, Edil BH, Herman JM, Hirose K, Schulick RD, Choti MA, Wolfgang CL, Pawlik TM |title=Conditional survival in patients with pancreatic ductal adenocarcinoma resected with curative intent |journal=Cancer |volume=118 |issue=10 |pages=2674–81 |year=2012 |pmid=21935914 |pmc=3578343 |doi=10.1002/cncr.26553 |url=}}</ref><ref name="pmid24038103">{{cite journal |vauthors=Sinn M, Striefler JK, Sinn BV, Sallmon D, Bischoff S, Stieler JM, Pelzer U, Bahra M, Neuhaus P, Dörken B, Denkert C, Riess H, Oettle H |title=Does long-term survival in patients with pancreatic cancer really exist? Results from the CONKO-001 study |journal=J Surg Oncol |volume=108 |issue=6 |pages=398–402 |year=2013 |pmid=24038103 |doi=10.1002/jso.23409 |url=}}</ref>
Pancreaticoduodenectomy (Whipple Procedure)<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid19387741">{{cite journal |vauthors=Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD |title=Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement |journal=Ann. Surg. Oncol. |volume=16 |issue=7 |pages=1736–44 |year=2009 |pmid=19387741 |doi=10.1245/s10434-009-0416-6 |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref>
Pancreaticoduodenectomy (Whipple Procedure)<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid19387741">{{cite journal |vauthors=Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD |title=Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement |journal=Ann. Surg. Oncol. |volume=16 |issue=7 |pages=1736–44 |year=2009 |pmid=19387741 |doi=10.1245/s10434-009-0416-6 |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref>
It is mainly performed for tumors located in:<ref name="pmid7794076">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA |title=Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients |journal=Ann. Surg. |volume=221 |issue=6 |pages=721–31; discussion 731–3 |year=1995 |pmid=7794076 |pmc=1234702 |doi= |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref><ref name="pmid8098202">{{cite journal |vauthors=Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J |title=One hundred and forty-five consecutive pancreaticoduodenectomies without mortality |journal=Ann. Surg. |volume=217 |issue=5 |pages=430–5; discussion 435–8 |year=1993 |pmid=8098202 |pmc=1242815 |doi= |url=}}</ref>
It is mainly performed for tumors located in:<ref name="pmid7794076">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA |title=Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients |journal=Ann. Surg. |volume=221 |issue=6 |pages=721–31; discussion 731–3 |year=1995 |pmid=7794076 |pmc=1234702 |doi= |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref><ref name="pmid8098202">{{cite journal |vauthors=Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J |title=One hundred and forty-five consecutive pancreaticoduodenectomies without mortality |journal=Ann. Surg. |volume=217 |issue=5 |pages=430–5; discussion 435–8 |year=1993 |pmid=8098202 |pmc=1242815 |doi= |url=}}</ref>
Line 94: Line 94:
After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage. Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref><ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>
After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage. Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref><ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>


  This procedure is associated with several morbidities:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref>
  This procedure is associated with several morbidities:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref><ref name="pmid11948273">{{cite journal |vauthors=Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE |title=Hospital volume and surgical mortality in the United States |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1128–37 |year=2002 |pmid=11948273 |doi=10.1056/NEJMsa012337 |url=}}</ref><ref name="pmid10455881">{{cite journal |vauthors=Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN |title=Relationship between hospital volume and late survival after pancreaticoduodenectomy |journal=Surgery |volume=126 |issue=2 |pages=178–83 |year=1999 |pmid=10455881 |doi= |url=}}</ref><ref name="pmid18926452">{{cite journal |vauthors=Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ |title=Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer |journal=J. Am. Coll. Surg. |volume=207 |issue=4 |pages=510–9 |year=2008 |pmid=18926452 |doi=10.1016/j.jamcollsurg.2008.04.033 |url=}}</ref><ref name="pmid14645640">{{cite journal |vauthors=Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL |title=Surgeon volume and operative mortality in the United States |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2117–27 |year=2003 |pmid=14645640 |doi=10.1056/NEJMsa035205 |url=}}</ref><ref name="pmid21500187">{{cite journal |vauthors=Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA |title=Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery |journal=Br J Surg |volume=98 |issue=4 |pages=485–94 |year=2011 |pmid=21500187 |doi=10.1002/bjs.7413 |url=}}</ref>
Postoperative abcess
Postoperative abcess
Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
Line 110: Line 110:
Distal Pancreatectomy <ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref>
Distal Pancreatectomy <ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref>
This procedure has a limited use in curative resection of pancreatic cancer.
This procedure has a limited use in curative resection of pancreatic cancer.
It is mainly performed for tumors located in:
It is mainly performed for tumors located in:<ref name="pmid8402126">{{cite journal |vauthors=Johnson CD, Schwall G, Flechtenmacher J, Trede M |title=Resection for adenocarcinoma of the body and tail of the pancreas |journal=Br J Surg |volume=80 |issue=9 |pages=1177–9 |year=1993 |pmid=8402126 |doi= |url=}}</ref>
Body of pancreas
Body of pancreas
Tail of pancreas
Tail of pancreas
Line 126: Line 126:
Leakage of pancreatic stump
Leakage of pancreatic stump


Total Pancreatectomy<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref>
Total Pancreatectomy<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref><ref name="pmid2539061">{{cite journal |vauthors=Brooks JR, Brooks DC, Levine JD |title=Total pancreatectomy for ductal cell carcinoma of the pancreas. An update |journal=Ann. Surg. |volume=209 |issue=4 |pages=405–10 |year=1989 |pmid=2539061 |pmc=1493970 |doi= |url=}}</ref><ref name="pmid1867520">{{cite journal |vauthors=Dresler CM, Fortner JG, McDermott K, Bajorunas DR |title=Metabolic consequences of (regional) total pancreatectomy |journal=Ann. Surg. |volume=214 |issue=2 |pages=131–40 |year=1991 |pmid=1867520 |pmc=1358512 |doi= |url=}}</ref><ref name="pmid6639161">{{cite journal |vauthors=Andrén-Sandberg A, Ihse I |title=Factors influencing survival after total pancreatectomy in patients with pancreatic cancer |journal=Ann. Surg. |volume=198 |issue=5 |pages=605–10 |year=1983 |pmid=6639161 |pmc=1353132 |doi= |url=}}</ref><ref name="pmid11146775">{{cite journal |vauthors=Karpoff HM, Klimstra DS, Brennan MF, Conlon KC |title=Results of total pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=136 |issue=1 |pages=44–7; discussion 48 |year=2001 |pmid=11146775 |doi= |url=}}</ref>




Line 134: Line 134:
Due to involvement of neck, patients develop insulin dependent DM.
Due to involvement of neck, patients develop insulin dependent DM.


Lymphadnectomy<ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref>
Lymphadnectomy<ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref><ref name="pmid24419758">{{cite journal |vauthors=Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW |title=Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage |journal=Ann. Surg. Oncol. |volume=21 |issue=5 |pages=1545–51 |year=2014 |pmid=24419758 |doi=10.1245/s10434-013-3473-9 |url=}}</ref>


Removal of positive nodes is preferrable, but some surgeons advocate extended lymphadnectomy.
Removal of positive nodes is preferrable, but some surgeons advocate extended lymphadnectomy.

Revision as of 16:59, 13 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]


In patients with pancreatic cancer, surgery is the primary modality of treatment. Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.Patients with unresectable disease are treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy. Curative resection is not contraindicated in all patients with vascular invasion.[1][2][3][4][5] Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.[6][7][8][9] However, the involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.[10] Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:[11][12][13][12]

  • Locally invasive characteristics of the neoplasm
  • Size
  • Location

Methods of curative resection options include:

    • Distal Pancreatectomy
  • Total pancreatectomy
  • Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis

The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:[14][15][16][17][18]

  • Patient selection is based on:
    • Resection margins
    • High probability of cure
    • Patient's age
    • Comorbidities

European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:[19][20][21][20][20][20]

  • Chemotherapy not preferred
  • Gemcitabine is preferred over 5 FU
  • Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice

In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:[22][22] Microwave ablation Photodynamic therapy Irreversible electroporation Photodynamic therapy High-intensity focused ultrasound (HIFU) Iodine-125–cryosurgery Iodine-125 Stereotactic body radiation therapy (SBRT) Radiofrequency ablation (RFA)

CHEMOTHERAPY

Metastatic disease/ Advanced pancreatic cancer which is unresectable:[23][24][25][26][27][28][29] The National Comprehensive Cancer Network (NCCN) has recommended guidelines for treatment in patients based on their performance status. In order to predict survival of patients in various stages of pancreatic cancer, the performance status of a patient is a major prognostic factor. Patients with poor prognostic factors have poor performance status. This includes-[30] Metastatic disease Large tumor Severe weight loss Therapy proposed for patients based on the resectability of disease and performance status is as follows:[31][32][33][34][35][36] In patients with locally advanced unresectable or metastatic disease with good performance status Preferred treatment: FOLFIRINOX[37][38][39][40][41][42][43][44][45][45][41][45] In patients with locally advanced unresectable or metastatic disease with good performance status with intolerance to FOLFIRINOX Preferred treatment:Paclitaxel protein bound+ Gemcitabine In patients with locally advanced unresectable or metastatic disease with poor performance status Preferred treatment: Gemcitabine monotherapy[46][47][48][49] In patients with locally advanced unresectable or metastatic disease with poor performance status refractory to Gemcitabine: Preferred treatment: Capecitabine or capecitabine+erlotinib[50] One year survival of FOLFIRINOX (leucovorin+5-lfuorouracil [LV5-FU]+oxaliplatin+irinotecan)>Gemcitabine[51][52][53][38][54][55][56] One year survival of Gemcitabine+ Erlotinib> Gemcitabine[57][58][28][28] One year survival of Gemcitabine+ Capecitabine≥Gemcitabine [59][60][61][32][62] One year survival of Gemcitabine+ nanoparticle albumin-bound (nab)-paclitaxel> Gemcitabine[63][64]


NEW TREATMENTS 

Irinotecan in an encapsulated form inside a nanoliposome is being used in advanced pancreatic cancer patients who have been earlier been treated using gemcitabine-based chemotherapy. [65]

Liposomal Irinotecan is used along with leucovorin and fluorouracil.[66]


ADJUVANT THERAPY The use of gemcitabine as adjuvant therapy is considered a standard form of therapy following surgical resection in pancreatic cancer patients.[67][68][69][70][71][72][73][74][75] NEOADJUVANT THERAPY Neoadjuvant therapy may be used as a form of therapy due to the following reasons:[76][77][78][79][25][41][80][61][34][81][82][83][84][85][41][25] Toxic effects of chemotherapy can be tolerated more easily before surgery as compared to after resection Shrinkage of tumor with neoadjuvant therapy makes resection easier and improves patient prognosis Systemic treatment for cancer involving various systems improves prognosis No therapy is considered as first line therapy under this category.Decisions for treatment are made on an individual basis.

SURGERY There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: [86][87][88][89][16][16][11][90][91][92][93][94][17][95][96][97][98][99][100][101][102][103][104][105] Pancreaticoduodenectomy (Whipple Procedure)[19][16][106][107] It is mainly performed for tumors located in:[108][107][109] Periampullary region Duodenum Bile duct (Cholangiocarcinoma) Pancreatic duct Head of pancreas Whipple procedure involves removal of the following components due to common blood supply: Stomach antrum Gallbladder Duodenum Head of pancreas After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage. Biliary drainage may also be performed preoperatively.[110][110] 

This procedure is associated with several morbidities:[111][112][113][114][115][116][117][118][119][120][121][122][123][124][125]

Postoperative abcess Wound infection[126] Anastomotic leak Delay in gastric emptying[127]

Pylorus sparing Whipple procedure:[128] The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy. This significantly reduces the incidence of nutritional deficiencies arising from this surgery.


The European Society for Medical Oncology states that the only curative therapy is surgical resection. Ten percent is the five year survival of patients with pancreatic cancer. Patients with node-positive tumors have very poor long term survival.

Distal Pancreatectomy [111] This procedure has a limited use in curative resection of pancreatic cancer. It is mainly performed for tumors located in:[129] Body of pancreas Tail of pancreas This form of surgery has fewer morbidities than the Whipple procedure.


Distal Pancreatectomy involves the following components: 

Separation of the distal pancreas bearing the tumor from the normal tissue
Resection of the affected portion

Oversewing of the distal pancreatic duct 

This procedure is associated with several morbidities:[130][131][132][133]

Pancreatic endocrine insufficiency Bleeding Leakage of pancreatic stump

Total Pancreatectomy[111][134][135][136][137][138]


It is the least preferred due to high mortality rate. It is mainly performed for tumors located in: Neck of the pancreas. Due to involvement of neck, patients develop insulin dependent DM.

Lymphadnectomy[139][140][98][99][141][98][99][142][143]

Removal of positive nodes is preferrable, but some surgeons advocate extended lymphadnectomy.

CA 19-9 level

Elevated levels of CA 19-9 can help in the following ways:[144]

Predicts the likelihood of complete resection

Prognosis of patients with resectable disease

Predicts the presence of occult metastases

However, CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.

PALLIATIVE THERAPY

Pain There are various techniques for pain management as palliative therapy in patients:

Narcotic analgesics Narcotic analgesics+ tricyclic antidepressants/ antiemetics Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction Radiation therapy Neurolysis of the celiac ganglia by many approaches Intraoperative Transgastric Transthoracic Transabdominal

Jaundice Obstructive jaundice can present with features of cholangitis: Fever and chills Nausea, vomiting Clay-colored stools Dark urine Yellowish discoloration of skin Pruritus Right upper quadrant pain Anorexia Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction Techniques of biliary decompression: Cholecystojejunostomy Choledochojejunostomy

Types of stents: Metal- costly, longer lifespan Plastic- cheaper, need replacement every three months

Duodenal obstruction Preferred treatment: Endoscopic stenting of duodenal obstruction Gastrojejunostomy

  1. ↑ Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T, Kim G, Noh K, Wallace MB (2007). "Vascular resection and reconstruction for pancreatic malignancy: a single center survival study". J. Gastrointest. Surg. 11 (9): 1168–74. doi:10.1007/s11605-007-0216-x. PMID 17632763.
  2. ↑ Donahue TR, Isacoff WH, Hines OJ, Tomlinson JS, Farrell JJ, Bhat YM, Garon E, Clerkin B, Reber HA (2011). "Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery". Arch Surg. 146 (7): 836–43. doi:10.1001/archsurg.2011.152. PMID 21768431.
  3. ↑ Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB (2004). "Pancreaticoduodenectomy with vascular resection: margin status and survival duration". J. Gastrointest. Surg. 8 (8): 935–49, discussion 949–50. doi:10.1016/j.gassur.2004.09.046. PMID 15585381.
  4. ↑ Martin RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA (2009). "Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes". Arch Surg. 144 (2): 154–9. doi:10.1001/archsurg.2008.547. PMID 19221327.
  5. ↑ Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE (2012). "The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database". Ann. Surg. Oncol. 19 (13): 4068–77. doi:10.1245/s10434-012-2585-y. PMID 22932857.
  6. ↑ Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB (1998). "Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head". Br J Surg. 85 (5): 611–7. doi:10.1046/j.1365-2168.1998.00641.x. PMID 9635805.
  7. ↑ Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB (1996). "Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group". Ann. Surg. 223 (2): 154–62. PMC 1235091. PMID 8597509.
  8. ↑ Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T (2013). "Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma". J Surg Oncol. 107 (4): 414–21. doi:10.1002/jso.23229. PMID 22886567.
  9. ↑ Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M (2009). "Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma?". Ann. Surg. Oncol. 16 (4): 817–25. doi:10.1245/s10434-008-0281-8. PMID 19156463.
  10. ↑ Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J (2011). "Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis". Ann. Surg. 254 (6): 882–93. doi:10.1097/SLA.0b013e31823ac299. PMID 22064622.
  11. ↑ 11.0 11.1 Ryan DP, Hong TS, Bardeesy N (2014). "Pancreatic adenocarcinoma". N. Engl. J. Med. 371 (11): 1039–49. doi:10.1056/NEJMra1404198. PMID 25207767.
  12. ↑ 12.0 12.1 Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M (2017). "Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma". Ann. Surg. 265 (1): 185–191. doi:10.1097/SLA.0000000000001763. PMID 27163957.
  13. ↑ Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS (2007). "Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database". Cancer. 110 (4): 738–44. doi:10.1002/cncr.22852. PMID 17580363.
  14. ↑ Fonseca AL, Fleming JB (2017). "Surgery for pancreatic cancer: critical radiologic findings for clinical decision making". Abdom Radiol (NY). doi:10.1007/s00261-017-1332-z. PMID 28948329.
  15. ↑ Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM (2014). "Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association". Radiology. 270 (1): 248–60. doi:10.1148/radiol.13131184. PMID 24354378.
  16. ↑ 16.0 16.1 16.2 16.3 Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH (2016). "Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline". J. Clin. Oncol. 34 (21): 2541–56. doi:10.1200/JCO.2016.67.5553. PMID 27247221.
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