Outcomes of pancreatic cancer (PDAC) therapy have dramatically improved during recent decades by progress in surgical techniques, centralization and embedding therapy in a multimodal approach – especially including adjuvant chemotherapy [1, 2].
Still, surgery is the only curative treatment approach [3], aiming at a complete removal of the tumor with tumor-free resection margins (R0) and resulting in long-term survival in a considerable number of patients. All surgical approaches should be combined with adjuvant chemotherapy, preferably performed with a combination of gemcitabine and capecitabine, by which a median survival of 28 months can be achieved [4].
Standard of care for PDACs in the pancreatic head is a pylorus-preserving duodenopancreatectomy. In PDACs located in the pancreatic body either a total duodenopancreatectomy or a subtotal resection of the left pancreas with splenectomy is performed. PDACs in the pancreatic tail are routinely treated by a distal pancreatectomy with splenectomy.
Besides standard resections, advanced PDAC surgery has evolved and various approaches in the setting of vascular or adjacent organ infiltration are currently performed as well as resections for oligometastatic PDAC or local tumor recurrences. According to the 2014 guidelines of the International Study Group for Pancreatic Surgery (ISGPS), infiltration of the mesenterico-portal vein generally does not prevent curative surgery of PDACs as surgical and oncological outcome after venous reconstruction is comparable to standard resections. The technique of venous resection and reconstruction depends on the localization and extent of tumor infiltration, ranging from simple lateral venorrhaphy to segmental resections with graft insertion [5]. The impact of neoadjuvant therapy in this situation remains controversial as available data and guideline recommendations (i.e. ISGPS [5], NCCN [6]) do not allow to draw evidence based conclusions and a number of studies on this topic are currently in progress, i.e. the ESPAC-5 trial [7].
Involvement of adjacent organs does not preclude patients from curative surgery as multivisceral resections – also in combination with venous reconstruction – can be performed with good perioperative and long-term outcome [8].
The regional lymph nodes should be cleared according to the recommendations of the ISGPS, implying lymphadenectomy in the hepato-duodenal ligament, along the right side of the celiac trunk and the superior mesenteric artery during duodenpancreatectomy. In distal pancreatectomy, the ligament and the corresponding left-sided lymphnodes along the celiac axis and the mesenteric artery should be removed and the lymph node ratio should be indicated in the pathology report since the LNR has prognostic value [9, 10].
In case of localized tumor recurrence without distant metastases, surgery should be evaluated and – if technically possible – performed, preferably following a neoadjuvant therapy as data on this approach show a superior outcome compared to palliative treatment [11].
For oligometastatic disease, surgery with primary tumor and metastases removal may be an option as an individual approach with encouraging results in selected patients as well as sequential surgery in case of metachronous metastases occurrence [12].



References
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