The surgical management of pancreatic cancer.

There have been significant advances made over the years in the areas of critical care, anesthesia, and surgical technique, which have led to improved mortality rates and survival after resection for pancreatic cancer. The standard of care is currently PD or PPPD for pancreatic cancers of the head, uncinate process, or neck and DP for pancreatic cancers of the body or tail. Resections are performed with the goals of negative margins and minimal blood loss, and referral to high-volume centers and surgeons is encouraged. However, 5-year survival rate after curative resection still remains at less than 20%. In an effort to improve survival and extend the limits of resectability, many centers have attempted extended lymphadenectomy and portal venous and even arterial resection and reconstruction. Extended lymphadenectomy has not led to improved survival for these patients. Portal vein resection has increased the number of patients amenable to resection, with equivalent survival rates compared with those of standard resections. Portal vein invasion is thus no longer considered a contraindication to resection at many large centers. Resection and reconstruction of involved arteries have been rarely performed and are currently not considerations for most patients. It is likely that future improvements in survival lie in the realm of adjuvant therapy. As chemotherapeutic and other tumor-directed agents continue to evolve and advance, this will hopefully lead to improved survival for patients undergoing surgical resection for pancreatic cancer.