Surgery for pancreatic cancer: current controversies and challenges

Lay abstract Two main areas of focus in pancreatic cancer research are the high rates of post-surgery complications and poor survival despite completely removing the tumor. Complete, margin-negative resection (where some healthy tissue is removed to ensure the whole tumor is cut out) is the only way to ensure long-term survival. However, such extensive resections, especially when they involve nearby blood vessels and/or organs, should only be undertaken if the imaging done pre-surgery indicates the possibility that a complete, margin-negative resection can be achieved. It should be noted that the removal of lymph nodes, in addition to the ones normally removed during a pancreatic resection, does not confer a survival benefit. Distal pancreatectomy (performed for tumors involving the body or tail of the pancreas) is safe and feasible using minimal access methods; however, the safety of minimally-invasive pancreatoduodenectomy (performed for tumors of the head of the pancreas) remains to be proven. The oncological benefit of minimally-invasive distal pancreatectomy over open surgery has not been established. Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.