Surgical resection of pancreatic head cancer: What is the optimal extent of surgery?

Extent of surgery should depend on curability. Improvements in surgical techniques have resulted in surgeons seeking to perform more radical surgery. To date, five randomized controlled trials (RCT) have analyzed the benefits of extended lymphadenectomy for pancreatic head cancer, but none has shown that extended lymphadenectomy enhances patient survival. As most patients with pancreatic cancer have microscopic, locally advanced disease that cannot be cured by surgery alone, local tumor control by extended lymphadenectomy cannot overcome the negative aspects of pre-existing lymph node metastasis. The most important factor improving overall survival following pancreatoduodenectomy in patients with pancreatic head cancer is proper systemic control of the disease rather than extensive local control. The long-term survival outcomes following adjuvant treatment in a large multi-center RCT suggest the need for aggressive systemic treatment. More attention must be paid to the benefits of adjuvant treatment, not only focusing on technical R0 resection. Surgical strategies for patients with pancreatic head cancer require more flexibility, with extent of surgery customized to individual patients, depending on tumor location and disease severity.