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Gastrointestinal Cancer

Surgical Treatment of Pancreatic Cancer Magnus Bergenfeldt1

and Åke Andrén-Sandberg2

1. Associate Professor of Surgery, Department of Surgical Gastroenterology, Herlev Hospital; 2. Professor of Surgery, Department of Surgery, Karolinska University Hospital


Surgical resection offers the only hope for cure of pancreatic carcinoma. Pancreaticoduodenectomy (Whipple’s operation) is the standard procedure for cancer in the right hemipancreas, while resection of the pancreatic tail is used for left-sided pancreatic cancer. Total pancreatomy is used for diffuse/multifocal disease, but has severe metabolic consequences. This article summarises recent advances in the field. Today, pancreatic resection has a post-operative mortality rate of a few per cent and the long-term outcome after curative resection has improved: a median survival of 12–24 months and a five-year survival of 10–20% can be expected. Various technical modifications of Whipple’s operation have been described, but generally they do not outperform the original procedure. More complex procedures including vascular resection and/or extended lymphadenectomy can also be performed safely today, but generally they do not result in a better outcome. Although surgery is crucial for the treatment of pancreatic cancer, it has become obvious that pancreatic cancer can only rarely be cured by surgery alone; therefore, recent advances in adjuvant oncological therapy are discussed.

Keywords Pancreatic cancer, surgery, technical modifications, extended pancreaticoduodenectomy, octreotide, adjuvant therapy, neoadjuvant therapy

Disclosure: The authors have no conflicts of interest to declare. Received: 31 August 2010 Accepted: 24 January 2011 Citation: European Oncology & Haematology, 2011;7(1):36–42 Correspondence: Magnus Bergenfeldt, Department of Surgical Gastroenterology, Herlev Hospital, Ringvej 75, 2730 Herlev, Denmark. E:

Despite many years of continuous effort, pancreatic carcinoma remains a highly lethal disease and a challenge to the medical community. Most patients will be diagnosed in an advanced stage of the disease and will be candidates for oncological palliative therapy or supportive care only. These patient groups have a life expectancy of only a few months. It is documented that less than one of these patients will be alive after five years.1,2

Surgical resection remains the

only hope for long-term survival, but this option is available only for patients with a tumour confined to the pancreas. In population studies, 5–12% of patients were candidates for pancreatic resection.3–6

The era of modern pancreatic surgery began with the introduction of pancreaticoduodenectomy (PD) in the US by Whipple in the late 1930s;7 however, the operation had previously been performed in Europe by Codivilla in 1898 and by Kausch in 1912.8

Whipple’s operation was soon

recognised as a demanding and complication-prone procedure. In the first few decades, mortality rates exceeding 20% were reported even by large institutions, and some authors suggested that the procedure should be abandoned in favour of safer bypass surgery.9,10


further development was inspired by some early surgical series with no case fatalities.11,12

procedure and the mortality rate should not exceed a few per cent (see Table 1).13–24

While PD (Whipple’s operation) is the standard procedure for cancer in the right hemipancreas, resection of the pancreatic tail is used for left-sided pancreatic cancer.25

Total pancreatomy is indicated for

diffuse or multifocal disease, but it is used judiciously as it inevitably causes severe metabolic consequences (complete endocrine and

36 Today, pancreatic surgery is a standard

exocrine insufficiency). Further pancreatic procedures have been designed, mostly as technical modifications of Whipple’s operation, to alleviate the short- and long-term complications of the procedure.

This article provides a summary of current standards in pancreatic surgery, with special reference to technical achievements and post-operative outcome. In the last section, the most recent advances in adjuvant oncological therapy are discussed. Although surgery is crucial in the treatment of pancreatic cancer, it is obvious that surgery alone cannot cure the disease in most cases. The grim reality is that the majority of resected patients will eventually succumb to locoregional and/or distant recurrent disease.

Classic Pancreaticoduodenectomy (Whipple’s Operation)

The original description by Whipple in 193526 was of a two-stage

procedure that initially aimed to diminish the consequences of coagulopathy due to malabsorption of vitamin K. Today, the term Whipple’s operation is used for an operation that includes en bloc resection of the pancreatic head and duodenum together with the antrum of the stomach, the gall bladder and the distal bile duct. The operation is reserved for pancreatic cancer confined to the pancreas, and the standard procedure is resection with microscopically cancer-free margins (R0-resection) including the regional lymph nodes. Therefore the pre-operative work-up aims to exclude patients with distant metastases (most commonly peritoneal spread and liver metastases) including those with overgrowth on adjacent anatomical structures. Several authors advocate that a pre-operative exploratory laparoscopy with laparoscopic ultrasound should be


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