Pancreatic cancer surgery: Difference between revisions

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__NOTOC__
__NOTOC__
{{Pancreatic cancer}}
{{Pancreatic cancer}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Cherry}}


==Overview==
==Overview==
The mainstay of therapy for pancreatic cancer is surgery. The most common surgical treatment for cancer involving the pancreas is the [[Pancreaticoduodenectomy|Whipple procedure]].
The mainstay of [[therapy]] for [[pancreatic cancer]] is [[surgery]]. The different surgical techniques that may be used for resectable [[pancreatic cancer]] include [[pancreaticoduodenectomy]] (Whipple Procedure), pylorus sparing [[Pancreaticoduodenectomy|Whipple procedure]], distal [[pancreatectomy]] and total [[pancreatectomy]]. The method of [[Resection|surgical resection]] depends on the locally invasive characteristics and [[Size consistency|size]] of the [[neoplasm]]. The ''National Comprehensive Cancer Network (NCCN)'' has recommended certain guidelines on resectability of [[Pancreatic cancer|pancreatic neoplasms]] based on [[resection]] margins, probability of cure, age, and comorbidities.  Extrapancreatic disease requires [[Palliative care|palliative therapy]] and curative [[resection]] is not performed in such patients. [[CA 19-9|CA19-9]] levels help predict the likelihood of complete [[resection]], the prognosis of patients with resectable [[disease]] and the presence of occult [[metastasis]].


==Surgery==
==Surgery==
In patients with pancreatic cancer, surgery is the primary modality of treatment.
* In patients with [[pancreatic cancer]], [[surgery]] is the primary modality of treatment.
Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
* Various methods of surgical [[resection]] may be employed and each of these has its own sets of risks and perioperative complications.
Patients with unresectable disease are treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy.
* The benefits, risks and complications are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical [[resection]] depends on the following features:<ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid27163957">{{cite journal |vauthors=Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M |title=Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma |journal=Ann. Surg. |volume=265 |issue=1 |pages=185–191 |year=2017 |pmid=27163957 |doi=10.1097/SLA.0000000000001763 |url=}}</ref><ref name="pmid17580363">{{cite journal |vauthors=Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS |title=Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database |journal=Cancer |volume=110 |issue=4 |pages=738–44 |year=2007 |pmid=17580363 |doi=10.1002/cncr.22852 |url=}}</ref>
Curative resection is not contraindicated in all patients with vascular invasion.
** Locally invasive characteristics of the [[neoplasm]]
Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.
** Size  
The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.
==== Criteria for Unresectability ====
Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:
*[[Tumor]] larger than 5 cm
Locally invasive characteristics of the neoplasm
*[[Tumor]] invading adjacent tissue of [[Organ (anatomy)|organs]] (excluding [[duodenum]])
Size
*Encasement, [[stenosis]], or occlusion of the [[celiac artery]], [[celiac artery]] branches, and/or [[Superior mesenteric|SMA]]
Surgical methods of curative resection include:
*Portal vein([[Portal vein|PV)]] and/or Superior Mesenteric Vein ([[Superior mesenteric vein|SMV)]] encasement (some centers will operate with [[Vein|venous]] invasion)
Distal Pancreatectomy
*[[Liver|Hepatic]] [[metastasis]]
Total pancreatectomy
*Distant [[metastasis]] (i.e. non regional [[Lymph node|lymph nodes]])
Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis.
*[[Peritoneal carcinomatosis]]
The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:
Surgical methods of curative [[resection]] include:  
Patient selection is based on:
* Distal [[pancreatectomy]]
Resection margins
* Total [[pancreatectomy]]
High probability of cure
* [[Pancreaticoduodenectomy]], where [[pylorus]] may or may not be spared on an individual basis  
Patient's age
The ''National Comprehensive Cancer Network (NCCN)'' has recommended certain guidelines on resectability of [[Pancreatic cancer|pancreatic neoplasms]] based on a statement passed by the ''American pancreatic association'':<ref name="pmid28948329">{{cite journal |vauthors=Fonseca AL, Fleming JB |title=Surgery for pancreatic cancer: critical radiologic findings for clinical decision making |journal=Abdom Radiol (NY) |volume= |issue= |pages= |year=2017 |pmid=28948329 |doi=10.1007/s00261-017-1332-z |url=}}</ref><ref name="pmid24354378">{{cite journal |vauthors=Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM |title=Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association |journal=Radiology |volume=270 |issue=1 |pages=248–60 |year=2014 |pmid=24354378 |doi=10.1148/radiol.13131184 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid27247216">{{cite journal |vauthors=Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, Javle MM, Eads JR, Allen P, Ko AH, Engebretson A, Herman JM, Strickler JH, Benson AB, Urba S, Yee NS |title=Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=22 |pages=2654–68 |year=2016 |pmid=27247216 |doi=10.1200/JCO.2016.67.5561 |url=}}</ref>
Comorbidities
* Patient selection is based on:  
The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:
** Resection margins  
Chemotherapy not preferred.
** High probability of cure  
Gemcitabine is preferred over 5 FU.
** Age of the patient
Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
** [[Comorbidity|Comorbidities]]
In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:
* Curative [[resection]] is not contraindicated in all patients with vascular [[Invasive (medical)|invasion]]:<ref name="pmid17632763">{{cite journal |vauthors=Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T, Kim G, Noh K, Wallace MB |title=Vascular resection and reconstruction for pancreatic malignancy: a single center survival study |journal=J. Gastrointest. Surg. |volume=11 |issue=9 |pages=1168–74 |year=2007 |pmid=17632763 |doi=10.1007/s11605-007-0216-x |url=}}</ref><ref name="pmid21768431">{{cite journal |vauthors=Donahue TR, Isacoff WH, Hines OJ, Tomlinson JS, Farrell JJ, Bhat YM, Garon E, Clerkin B, Reber HA |title=Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery |journal=Arch Surg |volume=146 |issue=7 |pages=836–43 |year=2011 |pmid=21768431 |doi=10.1001/archsurg.2011.152 |url=}}</ref><ref name="pmid15585381">{{cite journal |vauthors=Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB |title=Pancreaticoduodenectomy with vascular resection: margin status and survival duration |journal=J. Gastrointest. Surg. |volume=8 |issue=8 |pages=935–49; discussion 949–50 |year=2004 |pmid=15585381 |doi=10.1016/j.gassur.2004.09.046 |url=}}</ref><ref name="pmid19221327">{{cite journal |vauthors=Martin RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA |title=Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes |journal=Arch Surg |volume=144 |issue=2 |pages=154–9 |year=2009 |pmid=19221327 |doi=10.1001/archsurg.2008.547 |url=}}</ref><ref name="pmid22932857">{{cite journal |vauthors=Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE |title=The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database |journal=Ann. Surg. Oncol. |volume=19 |issue=13 |pages=4068–77 |year=2012 |pmid=22932857 |doi=10.1245/s10434-012-2585-y |url=}}</ref>
Microwave ablation
** Involvement of the [[Portal vein|portal]] or [[superior mesenteric vein]] can be resected and reconstructed with the help of [[Splenic vein|splenic]], [[Saphenous vein|saphenous]] or [[internal jugular vein]]<nowiki/>s.<ref name="pmid9635805">{{cite journal |vauthors=Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB |title=Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head |journal=Br J Surg |volume=85 |issue=5 |pages=611–7 |year=1998 |pmid=9635805 |doi=10.1046/j.1365-2168.1998.00641.x |url=}}</ref><ref name="pmid8597509">{{cite journal |vauthors=Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB |title=Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group |journal=Ann. Surg. |volume=223 |issue=2 |pages=154–62 |year=1996 |pmid=8597509 |pmc=1235091 |doi= |url=}}</ref><ref name="pmid22886567">{{cite journal |vauthors=Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T |title=Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma |journal=J Surg Oncol |volume=107 |issue=4 |pages=414–21 |year=2013 |pmid=22886567 |doi=10.1002/jso.23229 |url=}}</ref><ref name="pmid19156463">{{cite journal |vauthors=Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M |title=Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? |journal=Ann. Surg. Oncol. |volume=16 |issue=4 |pages=817–25 |year=2009 |pmid=19156463 |doi=10.1245/s10434-008-0281-8 |url=}}</ref>
Photodynamic therapy
** The involvement of arteries such as the [[Hepatic artery|hepatic]], [[Celiac artery|celiac]] or [[Superior mesenteric artery|superior mesenteric]] are contraindications to [[resection]].<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>
Irreversible electroporation
* Extrapancreatic disease requires [[Palliative care|palliative therapy]] and curative [[resection]] is not performed in such patients.
Photodynamic therapy
* The ''European Society for Medical Oncology (ESMO)'' has certain guidelines on the treatment of [[pancreatic cancer]]:<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid26122369">{{cite journal |vauthors=Evans DB, George B, Tsai S |title=Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3409–13 |year=2015 |pmid=26122369 |doi=10.1245/s10434-015-4649-2 |url=}}</ref>
High-intensity focused ultrasound (HIFU)
** The only curative therapy for [[pancreatic cancer]] is [[Resection|surgical resection]].
Iodine-125–cryosurgery
** The five year survival of patients with [[pancreatic cancer]] is 10 percent.
Iodine-125
** Patients with node-positive [[Tumor|tumors]] have very poor long term survival.
Stereotactic body radiation therapy (SBRT)
** [[Chemotherapy]] is not preferred [[Metastasis|metastatic cancer]].  
Radiofrequency ablation (RFA)
** [[Gemcitabine]] is preferred over 5 FU in case of [[metastasis]].  
** Treatment in case of [[Metastasis|metastatic cancer]] is symptomatic with bypass surgery or [[stent]] placement for [[gastric outlet obstruction]] or [[Jaundice|obstructive jaundice]].  
* In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:<ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref>
** Microwave ablation  
** [[Photodynamic therapy|Photodynamic]] therapy  
** Irreversible [[electroporation]]
** [[Photodynamic therapy]]
** [[High-intensity focused ultrasound|High-intensity focused ultrasound (HIFU)]]
** [[Iodine]]-125–[[cryosurgery]]
** [[Iodine]]-125  
** Stereotactic body [[radiation therapy]] (SBRT)  
** [[Radiofrequency ablation|Radiofrequency ablation (RFA)]]


:* In patients with pancreatic cancer, surgery is the primary modality of treatment.
* Treatment of [[pancreatic cancer]] depends on the stage of the [[cancer]].<ref>[http://pathology.jhu.edu/pancreas/TreatmentSurgery.php Pancreatic Cancer - Johns Hopkins Medicine: Surgical Treatment of Pancreatic Cancer<!-- Bot generated title -->]</ref> 
* There are different surgical techniques that may be used for resectable [[pancreatic cancer]] and their prognosis has been extensively studied: <ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid12972517">{{cite journal |vauthors=Krzyzanowska MK, Weeks JC, Earle CC |title=Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness |journal=J. Clin. 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:* Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
==== Pancreaticoduodenectomy (Whipple Procedure) ====
:* Patients with unresectable disease are treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy.
Various features of [[Whipple procedure]] are as follows:<ref name="pmid26314780" /><ref name="pmid27247221" /><ref name="pmid19387741">{{cite journal |vauthors=Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD |title=Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement |journal=Ann. Surg. Oncol. |volume=16 |issue=7 |pages=1736–44 |year=2009 |pmid=19387741 |doi=10.1245/s10434-009-0416-6 |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref><ref name="pmid16955382">{{cite journal |vauthors=Massucco P, Capussotti L, Magnino A, Sperti E, Gatti M, Muratore A, Sgotto E, Gabriele P, Aglietta M |title=Pancreatic resections after chemoradiotherapy for locally advanced ductal adenocarcinoma: analysis of perioperative outcome and survival |journal=Ann. Surg. Oncol. |volume=13 |issue=9 |pages=1201–8 |year=2006 |pmid=16955382 |doi=10.1245/s10434-006-9032-x |url=}}</ref><ref name="pmid22569924">{{cite journal |vauthors=Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA |title='Artery-first' approaches to pancreatoduodenectomy |journal=Br J Surg |volume=99 |issue=8 |pages=1027–35 |year=2012 |pmid=22569924 |doi=10.1002/bjs.8763 |url=}}</ref><ref name="pmid24912627">{{cite journal |vauthors=Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, Zhao H, Wen J, Du Y, Lau WY, Zhang Y |title=Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=World J Surg |volume=38 |issue=10 |pages=2708–15 |year=2014 |pmid=24912627 |doi=10.1007/s00268-014-2633-9 |url=}}</ref><ref name="pmid10399969">{{cite journal |vauthors=Millikan KW, Deziel DJ, Silverstein JC, Kanjo TM, Christein JD, Doolas A, Prinz RA |title=Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas |journal=Am Surg |volume=65 |issue=7 |pages=618–23; discussion 623–4 |year=1999 |pmid=10399969 |doi= |url=}}</ref>
:* Curative resection is not contraindicated in all patients with vascular invasion.<ref name="pmid17632763">{{cite journal |vauthors=Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T, Kim G, Noh K, Wallace MB |title=Vascular resection and reconstruction for pancreatic malignancy: a single center survival study |journal=J. Gastrointest. Surg. |volume=11 |issue=9 |pages=1168–74 |year=2007 |pmid=17632763 |doi=10.1007/s11605-007-0216-x |url=}}</ref><ref name="pmid21768431">{{cite journal |vauthors=Donahue TR, Isacoff WH, Hines OJ, Tomlinson JS, Farrell JJ, Bhat YM, Garon E, Clerkin B, Reber HA |title=Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery |journal=Arch Surg |volume=146 |issue=7 |pages=836–43 |year=2011 |pmid=21768431 |doi=10.1001/archsurg.2011.152 |url=}}</ref><ref name="pmid15585381">{{cite journal |vauthors=Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB |title=Pancreaticoduodenectomy with vascular resection: margin status and survival duration |journal=J. Gastrointest. Surg. |volume=8 |issue=8 |pages=935–49; discussion 949–50 |year=2004 |pmid=15585381 |doi=10.1016/j.gassur.2004.09.046 |url=}}</ref><ref name="pmid19221327">{{cite journal |vauthors=Martin RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA |title=Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes |journal=Arch Surg |volume=144 |issue=2 |pages=154–9 |year=2009 |pmid=19221327 |doi=10.1001/archsurg.2008.547 |url=}}</ref><ref name="pmid22932857">{{cite journal |vauthors=Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE |title=The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database |journal=Ann. Surg. Oncol. |volume=19 |issue=13 |pages=4068–77 |year=2012 |pmid=22932857 |doi=10.1245/s10434-012-2585-y |url=}}</ref>
* [[Whipple procedure]] is mainly performed for tumors located in:<ref name="pmid7794076">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA |title=Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients |journal=Ann. Surg. |volume=221 |issue=6 |pages=721–31; discussion 731–3 |year=1995 |pmid=7794076 |pmc=1234702 |doi= |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref><ref name="pmid8098202">{{cite journal |vauthors=Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J |title=One hundred and forty-five consecutive pancreaticoduodenectomies without mortality |journal=Ann. Surg. |volume=217 |issue=5 |pages=430–5; discussion 435–8 |year=1993 |pmid=8098202 |pmc=1242815 |doi= |url=}}</ref>  
:** Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.<ref name="pmid9635805">{{cite journal |vauthors=Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB |title=Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head |journal=Br J Surg |volume=85 |issue=5 |pages=611–7 |year=1998 |pmid=9635805 |doi=10.1046/j.1365-2168.1998.00641.x |url=}}</ref><ref name="pmid8597509">{{cite journal |vauthors=Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB |title=Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group |journal=Ann. Surg. |volume=223 |issue=2 |pages=154–62 |year=1996 |pmid=8597509 |pmc=1235091 |doi= |url=}}</ref><ref name="pmid22886567">{{cite journal |vauthors=Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T |title=Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma |journal=J Surg Oncol |volume=107 |issue=4 |pages=414–21 |year=2013 |pmid=22886567 |doi=10.1002/jso.23229 |url=}}</ref><ref name="pmid19156463">{{cite journal |vauthors=Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M |title=Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? |journal=Ann. Surg. Oncol. |volume=16 |issue=4 |pages=817–25 |year=2009 |pmid=19156463 |doi=10.1245/s10434-008-0281-8 |url=}}</ref>
** Periampullary region
:** The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>  
** [[Duodenum]]
:* Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:<ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid27163957">{{cite journal |vauthors=Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M |title=Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma |journal=Ann. Surg. |volume=265 |issue=1 |pages=185–191 |year=2017 |pmid=27163957 |doi=10.1097/SLA.0000000000001763 |url=}}</ref><ref name="pmid17580363">{{cite journal |vauthors=Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS |title=Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database |journal=Cancer |volume=110 |issue=4 |pages=738–44 |year=2007 |pmid=17580363 |doi=10.1002/cncr.22852 |url=}}</ref>  
** [[Bile duct]] ([[cholangiocarcinoma]])
:** Locally invasive characteristics of the neoplasm
** [[Pancreatic duct]]
:** Size
** Head of [[pancreas]]
:* Surgical methods of curative resection include:
* [[Whipple procedure]] involves removal of the following components due to common blood supply:  
:** Distal Pancreatectomy
** Stomach [[antrum]]
:** Total pancreatectomy
** [[Gallbladder]]
:**Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis.
** [[Duodenum]]
:*The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:<ref name="pmid28948329">{{cite journal |vauthors=Fonseca AL, Fleming JB |title=Surgery for pancreatic cancer: critical radiologic findings for clinical decision making |journal=Abdom Radiol (NY) |volume= |issue= |pages= |year=2017 |pmid=28948329 |doi=10.1007/s00261-017-1332-z |url=}}</ref><ref name="pmid24354378">{{cite journal |vauthors=Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM |title=Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association |journal=Radiology |volume=270 |issue=1 |pages=248–60 |year=2014 |pmid=24354378 |doi=10.1148/radiol.13131184 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid27247216">{{cite journal |vauthors=Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, Javle MM, Eads JR, Allen P, Ko AH, Engebretson A, Herman JM, Strickler JH, Benson AB, Urba S, Yee NS |title=Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=22 |pages=2654–68 |year=2016 |pmid=27247216 |doi=10.1200/JCO.2016.67.5561 |url=}}</ref>
** Head of [[pancreas]]
:*Patient selection is based on:
* After removal of the above structures, the biliary and distal [[Pancreatic duct|pancreatic ducts]] are anastomosed to the [[jejunum]] to facilitate surgical drainage.
:**Resection margins
* [[Bile duct|Biliary]] drainage may also be performed preoperatively to decrease chances of infection.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>
:**High probability of cure
:**Patient's age
:**Comorbidities
:*The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid26122369">{{cite journal |vauthors=Evans DB, George B, Tsai S |title=Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3409–13 |year=2015 |pmid=26122369 |doi=10.1245/s10434-015-4649-2 |url=}}</ref>
:**Chemotherapy not preferred.
:**Gemcitabine is preferred over 5 FU.
:**Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
:*In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:<ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref><ref name="pmid25524417" />
:**Microwave ablation
:**Photodynamic therapy
:**Irreversible electroporation
:**Photodynamic therapy
:**High-intensity focused ultrasound (HIFU)
:**Iodine-125–cryosurgery
:**Iodine-125
:**Stereotactic body radiation therapy (SBRT)
:**Radiofrequency ablation (RFA)


There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: <ref name="pmid12972517">{{cite journal |vauthors=Krzyzanowska MK, Weeks JC, Earle CC |title=Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness |journal=J. Clin. Oncol. |volume=21 |issue=18 |pages=3409–14 |year=2003 |pmid=12972517 |doi=10.1200/JCO.2003.03.007 |url=}}</ref><ref name="pmid16955382">{{cite journal |vauthors=Massucco P, Capussotti L, Magnino A, Sperti E, Gatti M, Muratore A, Sgotto E, Gabriele P, Aglietta M |title=Pancreatic resections after chemoradiotherapy for locally advanced ductal adenocarcinoma: analysis of perioperative outcome and survival |journal=Ann. Surg. Oncol. |volume=13 |issue=9 |pages=1201–8 |year=2006 |pmid=16955382 |doi=10.1245/s10434-006-9032-x |url=}}</ref><ref name="pmid12576921">{{cite journal |vauthors=Aristu J, Cañón R, Pardo F, Martínez-Monge R, Martin-Algarra S, Manuel Ordoñez J, Villafranca E, Moreno M, Cambeiro M, Azinovic I |title=Surgical resection after preoperative chemoradiotherapy benefits selected patients with unresectable pancreatic cancer |journal=Am. J. Clin. Oncol. |volume=26 |issue=1 |pages=30–6 |year=2003 |pmid=12576921 |doi= |url=}}</ref><ref name="pmid19576722">{{cite journal |vauthors=Turrini O, Viret F, Moureau-Zabotto L, Guiramand J, Moutardier V, Lelong B, Giovannini M, Delpero JR |title=Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma |journal=Eur J Surg Oncol |volume=35 |issue=12 |pages=1306–11 |year=2009 |pmid=19576722 |doi=10.1016/j.ejso.2009.06.005 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid28398845">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update |journal=J. Clin. Oncol. |volume=35 |issue=20 |pages=2324–2328 |year=2017 |pmid=28398845 |doi=10.1200/JCO.2017.72.4948 |url=}}</ref><ref name="pmid22569924">{{cite journal |vauthors=Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA |title='Artery-first' approaches to pancreatoduodenectomy |journal=Br J Surg |volume=99 |issue=8 |pages=1027–35 |year=2012 |pmid=22569924 |doi=10.1002/bjs.8763 |url=}}</ref><ref name="pmid24578248">{{cite journal |vauthors=Gurusamy KS, Kumar S, Davidson BR, Fusai G |title=Resection versus other treatments for locally advanced pancreatic cancer |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD010244 |year=2014 |pmid=24578248 |doi=10.1002/14651858.CD010244.pub2 |url=}}</ref><ref name="pmid18958561">{{cite journal |vauthors=Doi R, Imamura M, Hosotani R, Imaizumi T, Hatori T, Takasaki K, Funakoshi A, Wakasugi H, Asano T, Hishinuma S, Ogata Y, Sunamura M, Yamaguchi K, Tanaka M, Takao S, Aikou T, Hirata K, Maguchi H, Aiura K, Aoki T, Kakita A, Sasaki M, Ozaki M, Matsusue S, Higashide S, Noda H, Ikeda S, Maetani S, Yoshida S |title=Surgery versus radiochemotherapy for resectable locally invasive pancreatic cancer: final results of a randomized multi-institutional trial |journal=Surg. 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Surg. |volume=199 |issue=4 |pages=418–25 |year=1984 |pmid=6712317 |pmc=1353360 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid24912627">{{cite journal |vauthors=Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, Zhao H, Wen J, Du Y, Lau WY, Zhang Y |title=Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=World J Surg |volume=38 |issue=10 |pages=2708–15 |year=2014 |pmid=24912627 |doi=10.1007/s00268-014-2633-9 |url=}}</ref><ref name="pmid10399969">{{cite journal |vauthors=Millikan KW, Deziel DJ, Silverstein JC, Kanjo TM, Christein JD, Doolas A, Prinz RA |title=Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas |journal=Am Surg |volume=65 |issue=7 |pages=618–23; discussion 623–4 |year=1999 |pmid=10399969 |doi= |url=}}</ref><ref name="pmid11296108">{{cite journal |vauthors=Balcom JH, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C |title=Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization |journal=Arch Surg |volume=136 |issue=4 |pages=391–8 |year=2001 |pmid=11296108 |doi= |url=}}</ref><ref name="pmid25348784">{{cite journal |vauthors=Serrano PE, Cleary SP, Dhani N, Kim PT, Greig PD, Leung K, Moulton CA, Gallinger S, Wei AC |title=Improved long-term outcomes after resection of pancreatic adenocarcinoma: a comparison between two time periods |journal=Ann. Surg. Oncol. |volume=22 |issue=4 |pages=1160–7 |year=2015 |pmid=25348784 |doi=10.1245/s10434-014-4196-2 |url=}}</ref><ref name="pmid21935914">{{cite journal |vauthors=Mayo SC, Nathan H, Cameron JL, Olino K, Edil BH, Herman JM, Hirose K, Schulick RD, Choti MA, Wolfgang CL, Pawlik TM |title=Conditional survival in patients with pancreatic ductal adenocarcinoma resected with curative intent |journal=Cancer |volume=118 |issue=10 |pages=2674–81 |year=2012 |pmid=21935914 |pmc=3578343 |doi=10.1002/cncr.26553 |url=}}</ref><ref name="pmid24038103">{{cite journal |vauthors=Sinn M, Striefler JK, Sinn BV, Sallmon D, Bischoff S, Stieler JM, Pelzer U, Bahra M, Neuhaus P, Dörken B, Denkert C, Riess H, Oettle H |title=Does long-term survival in patients with pancreatic cancer really exist? Results from the CONKO-001 study |journal=J Surg Oncol |volume=108 |issue=6 |pages=398–402 |year=2013 |pmid=24038103 |doi=10.1002/jso.23409 |url=}}</ref>
* [[Pancreaticoduodenectomy|Whipple procedure]] is associated with several morbidities that may increase patient mortality:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref><ref name="pmid11948273">{{cite journal |vauthors=Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE |title=Hospital volume and surgical mortality in the United States |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1128–37 |year=2002 |pmid=11948273 |doi=10.1056/NEJMsa012337 |url=}}</ref><ref name="pmid10455881">{{cite journal |vauthors=Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN |title=Relationship between hospital volume and late survival after pancreaticoduodenectomy |journal=Surgery |volume=126 |issue=2 |pages=178–83 |year=1999 |pmid=10455881 |doi= |url=}}</ref><ref name="pmid18926452">{{cite journal |vauthors=Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ |title=Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer |journal=J. Am. Coll. Surg. |volume=207 |issue=4 |pages=510–9 |year=2008 |pmid=18926452 |doi=10.1016/j.jamcollsurg.2008.04.033 |url=}}</ref><ref name="pmid14645640">{{cite journal |vauthors=Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL |title=Surgeon volume and operative mortality in the United States |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2117–27 |year=2003 |pmid=14645640 |doi=10.1056/NEJMsa035205 |url=}}</ref><ref name="pmid21500187">{{cite journal |vauthors=Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA |title=Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery |journal=Br J Surg |volume=98 |issue=4 |pages=485–94 |year=2011 |pmid=21500187 |doi=10.1002/bjs.7413 |url=}}</ref>
Pancreaticoduodenectomy (Whipple Procedure)<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid19387741">{{cite journal |vauthors=Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD |title=Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement |journal=Ann. Surg. Oncol. |volume=16 |issue=7 |pages=1736–44 |year=2009 |pmid=19387741 |doi=10.1245/s10434-009-0416-6 |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref>
** Postoperative [[abscess]]
It is mainly performed for tumors located in:<ref name="pmid7794076">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA |title=Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients |journal=Ann. Surg. |volume=221 |issue=6 |pages=721–31; discussion 731–3 |year=1995 |pmid=7794076 |pmc=1234702 |doi= |url=}}</ref><ref name="pmid9339931">{{cite journal |vauthors=Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA |title=Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes |journal=Ann. Surg. |volume=226 |issue=3 |pages=248–57; discussion 257–60 |year=1997 |pmid=9339931 |pmc=1191017 |doi= |url=}}</ref><ref name="pmid8098202">{{cite journal |vauthors=Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J |title=One hundred and forty-five consecutive pancreaticoduodenectomies without mortality |journal=Ann. Surg. |volume=217 |issue=5 |pages=430–5; discussion 435–8 |year=1993 |pmid=8098202 |pmc=1242815 |doi= |url=}}</ref>
** [[Wound]] [[infection]]<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
Periampullary region
** [[Anastomosis|Anastomotic]] leak
Duodenum
** Delay in [[Stomach|gastric]] emptying<ref name="pmid17981197">{{cite journal |vauthors=Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW |title=Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) |journal=Surgery |volume=142 |issue=5 |pages=761–8 |year=2007 |pmid=17981197 |doi=10.1016/j.surg.2007.05.005 |url=}}</ref>
Bile duct (Cholangiocarcinoma)
Pancreatic duct
Head of pancreas
Whipple procedure involves removal of the following components due to common blood supply:
Stomach antrum
Gallbladder
Duodenum
Head of pancreas
After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage. Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref><ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>


This procedure is associated with several morbidities:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref><ref name="pmid11948273">{{cite journal |vauthors=Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE |title=Hospital volume and surgical mortality in the United States |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1128–37 |year=2002 |pmid=11948273 |doi=10.1056/NEJMsa012337 |url=}}</ref><ref name="pmid10455881">{{cite journal |vauthors=Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN |title=Relationship between hospital volume and late survival after pancreaticoduodenectomy |journal=Surgery |volume=126 |issue=2 |pages=178–83 |year=1999 |pmid=10455881 |doi= |url=}}</ref><ref name="pmid18926452">{{cite journal |vauthors=Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ |title=Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer |journal=J. Am. Coll. Surg. |volume=207 |issue=4 |pages=510–9 |year=2008 |pmid=18926452 |doi=10.1016/j.jamcollsurg.2008.04.033 |url=}}</ref><ref name="pmid14645640">{{cite journal |vauthors=Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL |title=Surgeon volume and operative mortality in the United States |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2117–27 |year=2003 |pmid=14645640 |doi=10.1056/NEJMsa035205 |url=}}</ref><ref name="pmid21500187">{{cite journal |vauthors=Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA |title=Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery |journal=Br J Surg |volume=98 |issue=4 |pages=485–94 |year=2011 |pmid=21500187 |doi=10.1002/bjs.7413 |url=}}</ref>
==== Pylorus sparing Whipple procedure ====
Postoperative abcess
* The [[pylorus]] may be spared as a modification of [[Pancreaticoduodenectomy|Whipple procedure]] to decrease gastric emptying due to [[antrectomy]].<ref name="pmid7908796">{{cite journal |vauthors=Tsao JI, Rossi RL, Lowell JA |title=Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation |journal=Arch Surg |volume=129 |issue=4 |pages=405–12 |year=1994 |pmid=7908796 |doi= |url=}}</ref><ref name="pmid26905229">{{cite journal |vauthors=Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, Diener MK |title=Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma |journal=Cochrane Database Syst Rev |volume=2 |issue= |pages=CD006053 |year=2016 |pmid=26905229 |doi=10.1002/14651858.CD006053.pub6 |url=}}</ref>
Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
* [[Pylorus]] sparing surgery significantly reduces the incidence of [[List of illnesses caused by poor nutrition|nutritional deficiencies]] arising from this surgery.
Anastomotic leak
Delay in gastric emptying<ref name="pmid17981197">{{cite journal |vauthors=Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW |title=Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) |journal=Surgery |volume=142 |issue=5 |pages=761–8 |year=2007 |pmid=17981197 |doi=10.1016/j.surg.2007.05.005 |url=}}</ref>
Pylorus sparing Whipple procedure:<ref name="pmid7908796">{{cite journal |vauthors=Tsao JI, Rossi RL, Lowell JA |title=Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation |journal=Arch Surg |volume=129 |issue=4 |pages=405–12 |year=1994 |pmid=7908796 |doi= |url=}}</ref>
The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy. This significantly reduces the incidence of nutritional deficiencies arising from this surgery.


==== Distal Pancreatectomy ====
* This procedure has a limited use in curative [[resection]] of [[pancreatic cancer]]. <ref name="pmid17667503" /><ref name="pmid2910241">{{cite journal |vauthors=Sindelar WF |title=Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=124 |issue=1 |pages=127–32 |year=1989 |pmid=2910241 |doi= |url=}}</ref><ref name="pmid27043078">{{cite journal |vauthors=Riviere D, Gurusamy KS, Kooby DA, Vollmer CM, Besselink MG, Davidson BR, van Laarhoven CJ |title=Laparoscopic versus open distal pancreatectomy for pancreatic cancer |journal=Cochrane Database Syst Rev |volume=4 |issue= |pages=CD011391 |year=2016 |pmid=27043078 |doi=10.1002/14651858.CD011391.pub2 |url=}}</ref>
* It is mainly performed for tumors located in:<ref name="pmid8402126">{{cite journal |vauthors=Johnson CD, Schwall G, Flechtenmacher J, Trede M |title=Resection for adenocarcinoma of the body and tail of the pancreas |journal=Br J Surg |volume=80 |issue=9 |pages=1177–9 |year=1993 |pmid=8402126 |doi= |url=}}</ref><ref>Retrieved from http://pathology.jhu.edu/pancreas/TreatmentSurgery.php.</ref>
** Body of [[pancreas]]
** Tail of [[pancreas]]
* Distal [[Pancreatectomy]] involves the following components:
** Separation of the distal [[pancreas]] bearing the [[tumor]] from the normal tissue.
** Resection of the affected portion.
** Oversewing of the distal [[pancreatic duct]].
* This form of surgery has fewer morbidities than the [[Pancreaticoduodenectomy|Whipple procedure]].
* This procedure is associated with the following morbidities:<ref name="pmid28406793">{{cite journal |vauthors=Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI |title=Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection |journal=Perm J |volume=21 |issue= |pages= |year=2017 |pmid=28406793 |pmc=5391783 |doi=10.7812/TPP/16-095 |url=}}</ref><ref name="pmid28347869">{{cite journal |vauthors=Liu A, Carmichael KA, Schallom ME, Klinkenberg WD |title=Retrospective review of postoperative glycemic control in patients after distal pancreatectomy |journal=Int J Surg |volume=41 |issue= |pages=86–90 |year=2017 |pmid=28347869 |doi=10.1016/j.ijsu.2017.03.060 |url=}}</ref><ref name="pmid28272344">{{cite journal |vauthors=Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G |title=Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection |journal=Nutrients |volume=9 |issue=3 |pages= |year=2017 |pmid=28272344 |pmc=5372906 |doi=10.3390/nu9030243 |url=}}</ref><ref name="pmid27763684">{{cite journal |vauthors=Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW |title=Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery |journal=Br J Surg |volume=104 |issue=1 |pages=108–117 |year=2017 |pmid=27763684 |doi=10.1002/bjs.10316 |url=}}</ref>
** [[Pancreas|Pancreatic]] [[Endocrine system|endocrine]] insufficiency
** [[Bleeding]]
** Leakage of [[Pancreas|pancreatic]] stump


The European Society for Medical Oncology states that the only curative therapy is surgical resection.  
==== Total Pancreatectomy ====
Ten percent is the five year survival of patients with pancreatic cancer.
Various features of total pancreatectomy are as follows:<ref name="pmid17667503" /><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref><ref name="pmid2539061">{{cite journal |vauthors=Brooks JR, Brooks DC, Levine JD |title=Total pancreatectomy for ductal cell carcinoma of the pancreas. An update |journal=Ann. Surg. |volume=209 |issue=4 |pages=405–10 |year=1989 |pmid=2539061 |pmc=1493970 |doi= |url=}}</ref><ref name="pmid1867520">{{cite journal |vauthors=Dresler CM, Fortner JG, McDermott K, Bajorunas DR |title=Metabolic consequences of (regional) total pancreatectomy |journal=Ann. Surg. |volume=214 |issue=2 |pages=131–40 |year=1991 |pmid=1867520 |pmc=1358512 |doi= |url=}}</ref><ref name="pmid6639161">{{cite journal |vauthors=Andrén-Sandberg A, Ihse I |title=Factors influencing survival after total pancreatectomy in patients with pancreatic cancer |journal=Ann. Surg. |volume=198 |issue=5 |pages=605–10 |year=1983 |pmid=6639161 |pmc=1353132 |doi= |url=}}</ref><ref name="pmid11146775">{{cite journal |vauthors=Karpoff HM, Klimstra DS, Brennan MF, Conlon KC |title=Results of total pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=136 |issue=1 |pages=44–7; discussion 48 |year=2001 |pmid=11146775 |doi= |url=}}</ref><ref name="pmid27879138">{{cite journal |vauthors=Ryska M, Rudiš J |title=[Total pancreatectomy for pancreatic malignancy - from history to the present day] |language=Czech |journal=Rozhl Chir |volume=95 |issue=10 |pages=345–349 |year=Fall 2016 |pmid=27879138 |doi= |url=}}</ref><ref name="pmid27605208">{{cite journal |vauthors=Del Chiaro M, Rangelova E, Segersvärd R, Arnelo U |title=Are there still indications for total pancreatectomy? |journal=Updates Surg |volume=68 |issue=3 |pages=257–263 |year=2016 |pmid=27605208 |pmc=5123621 |doi=10.1007/s13304-016-0388-6 |url=}}</ref>
Patients with node-positive tumors have very poor long term survival.
* Total [[pancreatectomy]] is the least preferred [[surgery]] due to high mortality rate.
* Total [[pancreatectomy]] is mainly performed for tumors located in:
** Neck of the [[pancreas]]
* Involvement of the neck of pancreas may lead to the development of [[insulin]] dependent [[Diabetes mellitus|DM]].


Distal Pancreatectomy <ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref>
==== Lymphadnectomy ====
This procedure has a limited use in curative resection of pancreatic cancer.
* Removal of positive [[Lymph nodes|nodes]] is preferrable, but some surgeons prefer extended as opposed to standard [[lymphadenectomy]].<ref name="pmid12192322" /><ref name="pmid16269290" /><ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref><ref name="pmid24419758">{{cite journal |vauthors=Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW |title=Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage |journal=Ann. Surg. Oncol. |volume=21 |issue=5 |pages=1545–51 |year=2014 |pmid=24419758 |doi=10.1245/s10434-013-3473-9 |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref>
It is mainly performed for tumors located in:<ref name="pmid8402126">{{cite journal |vauthors=Johnson CD, Schwall G, Flechtenmacher J, Trede M |title=Resection for adenocarcinoma of the body and tail of the pancreas |journal=Br J Surg |volume=80 |issue=9 |pages=1177–9 |year=1993 |pmid=8402126 |doi= |url=}}</ref>
Body of pancreas
Tail of pancreas
This form of surgery has fewer morbidities than the Whipple procedure.


==== CA 19-9 level ====
Distal Pancreatectomy involves the following components:
* Elevated levels of [[CA 19-9|CA19-9]] can help in the following ways:<ref name="pmid27049786">{{cite journal |vauthors=Bergquist JR, Puig CA, Shubert CR, Groeschl RT, Habermann EB, Kendrick ML, Nagorney DM, Smoot RL, Farnell MB, Truty MJ |title=Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study |journal=J. Am. Coll. Surg. |volume=223 |issue=1 |pages=52–65 |year=2016 |pmid=27049786 |doi=10.1016/j.jamcollsurg.2016.02.009 |url=}}</ref>  
Separation of the distal pancreas bearing the tumor from the normal tissue
** Predict the likelihood of complete [[resection]]
Resection of the affected portion
** Predict prognosis of patients with resectable pancreatic cancer  
Oversewing of the distal pancreatic duct
** Predict the presence of occult [[metastasis]]
 
* [[CA 19-9|CA19-9]] levels are not used to dictate the initial strategy for treatment of [[pancreatic cancer]].
This procedure is associated with several morbidities:<ref name="pmid28406793">{{cite journal |vauthors=Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI |title=Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection |journal=Perm J |volume=21 |issue= |pages= |year=2017 |pmid=28406793 |pmc=5391783 |doi=10.7812/TPP/16-095 |url=}}</ref><ref name="pmid28347869">{{cite journal |vauthors=Liu A, Carmichael KA, Schallom ME, Klinkenberg WD |title=Retrospective review of postoperative glycemic control in patients after distal pancreatectomy |journal=Int J Surg |volume=41 |issue= |pages=86–90 |year=2017 |pmid=28347869 |doi=10.1016/j.ijsu.2017.03.060 |url=}}</ref><ref name="pmid28272344">{{cite journal |vauthors=Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G |title=Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection |journal=Nutrients |volume=9 |issue=3 |pages= |year=2017 |pmid=28272344 |pmc=5372906 |doi=10.3390/nu9030243 |url=}}</ref><ref name="pmid27763684">{{cite journal |vauthors=Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW |title=Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery |journal=Br J Surg |volume=104 |issue=1 |pages=108–117 |year=2017 |pmid=27763684 |doi=10.1002/bjs.10316 |url=}}</ref>
Pancreatic endocrine insufficiency
Bleeding
Leakage of pancreatic stump
 
Total Pancreatectomy<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref><ref name="pmid2539061">{{cite journal |vauthors=Brooks JR, Brooks DC, Levine JD |title=Total pancreatectomy for ductal cell carcinoma of the pancreas. An update |journal=Ann. Surg. |volume=209 |issue=4 |pages=405–10 |year=1989 |pmid=2539061 |pmc=1493970 |doi= |url=}}</ref><ref name="pmid1867520">{{cite journal |vauthors=Dresler CM, Fortner JG, McDermott K, Bajorunas DR |title=Metabolic consequences of (regional) total pancreatectomy |journal=Ann. Surg. |volume=214 |issue=2 |pages=131–40 |year=1991 |pmid=1867520 |pmc=1358512 |doi= |url=}}</ref><ref name="pmid6639161">{{cite journal |vauthors=Andrén-Sandberg A, Ihse I |title=Factors influencing survival after total pancreatectomy in patients with pancreatic cancer |journal=Ann. Surg. |volume=198 |issue=5 |pages=605–10 |year=1983 |pmid=6639161 |pmc=1353132 |doi= |url=}}</ref><ref name="pmid11146775">{{cite journal |vauthors=Karpoff HM, Klimstra DS, Brennan MF, Conlon KC |title=Results of total pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=136 |issue=1 |pages=44–7; discussion 48 |year=2001 |pmid=11146775 |doi= |url=}}</ref>


=== Palliative Therapy===
Palliative therapy in patients with pancreatic cancer mainly involves the management of symptoms arising as a result of complications of surgery:<ref name="pmid28890822">{{cite journal |vauthors=Kulaylat AS, Mirkin KA, Hollenbeak CS, Wong J |title=Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: a U.S. population-based study |journal=J Gastrointest Oncol |volume=8 |issue=4 |pages=710–720 |year=2017 |pmid=28890822 |pmc=5582050 |doi=10.21037/jgo.2017.06.01 |url=}}</ref><ref name="pmid28850428">{{cite journal |vauthors=Mastenbroek TC, Kramp-Hendriks BJ, Kallewaard JW, Vonk JM |title=Multimodal intrathecal analgesia in refractory cancer pain |journal=Scand J Pain |volume=14 |issue= |pages=39–43 |year=2017 |pmid=28850428 |doi=10.1016/j.sjpain.2016.10.002 |url=}}</ref><ref name="pmid28772092">{{cite journal |vauthors=Schenker Y, Bahary N, Claxton R, Childers J, Chu E, Kavalieratos D, King L, Lembersky B, Tiver G, Arnold RM |title=A Pilot Trial of Early Specialty Palliative Care for Patients with Advanced Pancreatic Cancer: Challenges Encountered and Lessons Learned |journal=J Palliat Med |volume= |issue= |pages= |year=2017 |pmid=28772092 |doi=10.1089/jpm.2017.0113 |url=}}</ref><ref name="pmid28734721">{{cite journal |vauthors=Ouyang H, Ma W, Liu F, Yue Z, Fang M, Quan M, Pan Z |title=Factors influencing survival of patients with pancreatic adenocarcinoma and synchronous liver metastases receiving palliative care |journal=Pancreatology |volume=17 |issue=5 |pages=773–781 |year=2017 |pmid=28734721 |doi=10.1016/j.pan.2017.07.002 |url=}}</ref><ref name="pmid28705009">{{cite journal |vauthors=Agarwal R, Epstein AS |title=Palliative care and advance care planning for pancreas and other cancers |journal=Chin Clin Oncol |volume=6 |issue=3 |pages=32 |year=2017 |pmid=28705009 |doi=10.21037/cco.2017.06.16 |url=}}</ref><ref name="pmid28612201">{{cite journal |vauthors=Laquente B, Calsina-Berna A, Carmona-Bayonas A, Jiménez-Fonseca P, Peiró I, Carrato A |title=Supportive care in pancreatic ductal adenocarcinoma |journal=Clin Transl Oncol |volume= |issue= |pages= |year=2017 |pmid=28612201 |doi=10.1007/s12094-017-1682-6 |url=}}</ref><ref name="pmid28567456">{{cite journal |vauthors=Kayaalp C, Dogan MS, Ersan V |title=Surgery for intractable pain in a patient with chronic pancreatitis complicated with biliary obstruction, portal vein stenosis and mesenteric venous collaterals |journal=Ann Hepatobiliary Pancreat Surg |volume=21 |issue=2 |pages=101–105 |year=2017 |pmid=28567456 |pmc=5449365 |doi=10.14701/ahbps.2017.21.2.101 |url=}}</ref><ref name="pmid26898789">{{cite journal |vauthors=Hucl T |title=[Malignant biliary obstruction] |language=Czech |journal=Cas. Lek. Cesk. |volume=155 |issue=1 |pages=30–7 |year=2016 |pmid=26898789 |doi= |url=}}</ref>
==== Pain:  ====
* There are various techniques for [[pain]] management as [[Palliative care|palliative therapy]] in patients.


It is the least preferred due to high mortality rate.
* Surgical techniques used to treat [[pain]] in advanced [[pancreatic cancer]] include:
It is mainly performed for tumors located in:
** [[Endoscopy|Endoscopic]] [[decompression]] with [[stent]] placement in patients with [[Bile duct|biliary]] or [[pancreatic duct]] [[obstruction]]
Neck of the pancreas.
** [[Neurolysis]] of the [[celiac ganglia]] by approaches, such as:
Due to involvement of neck, patients develop insulin dependent DM.
*** Intraoperative
*** Transgastric
*** Transthoracic
*** Transabdominal


Lymphadnectomy<ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref><ref name="pmid24419758">{{cite journal |vauthors=Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW |title=Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage |journal=Ann. Surg. Oncol. |volume=21 |issue=5 |pages=1545–51 |year=2014 |pmid=24419758 |doi=10.1245/s10434-013-3473-9 |url=}}</ref>
==== Jaundice: ====
* [[Jaundice|Obstructive jaundice]] can present with features of [[cholangitis]]:
** [[Fever]] and [[Rigor|chills]]
** [[Nausea and vomiting|Nausea]], [[Nausea and vomiting|vomiting]]
** [[Acholic stools|Clay-colored stools]]
** Dark [[urine]]
** Yellowish discoloration of skin
** [[Itch|Pruritus]]
** [[Abdominal pain|Right upper quadrant pain]]
** [[Anorexia]]
* Preferred treatment in patients with obstructive jaundice:
** [[Endoscopy|Endoscopic]] [[decompression]] with [[stent]] placement in patients with [[Bile duct|biliary]] [[obstruction]].  
* Techniques of [[Bile duct|biliary]] [[decompression]]:  
** ''Cholecystojejunostomy''
** ''Choledochojejunostomy''


Removal of positive nodes is preferrable, but some surgeons advocate extended lymphadnectomy.
*Types of [[Stent|stents]]:
 
CA 19-9 level
 
Elevated levels of CA 19-9 can help in the following ways:<ref name="pmid27049786">{{cite journal |vauthors=Bergquist JR, Puig CA, Shubert CR, Groeschl RT, Habermann EB, Kendrick ML, Nagorney DM, Smoot RL, Farnell MB, Truty MJ |title=Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study |journal=J. Am. Coll. Surg. |volume=223 |issue=1 |pages=52–65 |year=2016 |pmid=27049786 |doi=10.1016/j.jamcollsurg.2016.02.009 |url=}}</ref>
 
Predicts the likelihood of complete resection
 
Prognosis of patients with resectable disease
 
Predicts the presence of occult metastases
 
However, CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.
 
PALLIATIVE THERAPY
 
=== Palliative Therapy===
*Pain:
**There are various techniques for pain management as palliative therapy in patients:
**Narcotic analgesics
**Narcotic analgesics+ tricyclic antidepressants/ antiemetics
**Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
**Radiation therapy
**Neurolysis of the celiac ganglia by many approaches:
***Intraoperative
***Transgastric
***Transthoracic
***Transabdominal
*Jaundice:
**Obstructive jaundice can present with features of cholangitis:
***Fever and chills
***Nausea, vomiting
***Clay-colored stools
***Dark urine
***Yellowish discoloration of skin
***Pruritus
***Right upper quadrant pain
***Anorexia
***Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction
****Techniques of biliary decompression:
*****Cholecystojejunostomy
*****Choledochojejunostomy
 
*Types of stents:
**Metal- costly, longer lifespan
**Metal- costly, longer lifespan
**Plastic- cheaper, need replacement every three months
**Plastic- cheaper, need replacement every three months


*Duodenal obstruction
==== Duodenal obstruction ====
**Preferred treatment:
* Preferred treatment:  
***Endoscopic stenting of duodenal obstruction
** [[Endoscopy|Endoscopic]] [[Stent|stenting]] of [[Duodenum|duodenal]] [[obstruction]]  
***Gastrojejunostomy
** [[Gastrojejunostomy]]
Pain
There are various techniques for pain management as palliative therapy in patients:
 
Narcotic analgesics
Narcotic analgesics+ tricyclic antidepressants/ antiemetics
Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
Radiation therapy
Neurolysis of the celiac ganglia by many approaches
Intraoperative
Transgastric
Transthoracic
Transabdominal
 
Jaundice
Obstructive jaundice can present with features of cholangitis:
Fever and chills
Nausea, vomiting
Clay-colored stools
Dark urine
Yellowish discoloration of skin
Pruritus
Right upper quadrant pain
Anorexia
Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction
Techniques of biliary decompression:
Cholecystojejunostomy
Choledochojejunostomy
 
Types of stents:
Metal- costly, longer lifespan
Plastic- cheaper, need replacement every three months
Duodenal obstruction
Preferred treatment:
Endoscopic stenting of duodenal obstruction
Gastrojejunostomy
 
Treatment of pancreatic cancer depends on the stage of the cancer.<ref>[http://pathology.jhu.edu/pancreas/TreatmentSurgery.php Pancreatic Cancer - Johns Hopkins Medicine: Surgical Treatment of Pancreatic Cancer<!-- Bot generated title -->]</ref> The [[Pancreaticoduodenectomy|Whipple procedure]] is the most common surgical treatment for cancers involving the head of the pancreas. It can only be performed if the patient is likely to survive major surgery and if the cancer is localised without invading local structures or metastasizing. It can therefore only be performed in the minority of cases.
 
[[Spleen]]-preserving distal pancreatectomy can also be used as a method to remove a cancer  running through center of the pancreas; this is invasive surgery, resulting in loss of body and tail. Cancers of the t for pancreatic cancer uail of the pancreas can be resected using a procedure known as a distal pancreatectomy.<ref>Retrieved from http://pathology.jhu.edu/pancreas/TreatmentSurgery.php.</ref>  Recently, localized cancers of the pancreas have been resected using minimally invasive (laparoscopic) approaches.
 
Surgery can be performed for palliation, if the malignancy is invading or compressing the [[duodenum]] or [[colon (anatomy)|colon]]. In that case, bypass surgery might overcome the obstruction and improve quality of life, but it is not intended as a cure.
 
===Post-Operative Management===
 
After surgery, ''adjuvant'' chemotherapy with [[gemcitabine]] may be offered to eliminate whatever cancerous tissue may remain in the body. This has been shown to increase 5-year survival rates. Addition of [[radiation therapy]] is a hotly debated topic, with groups in the US often favoring the use of adjuvant radiation therapy, while groups in Europe do not.<ref name="pmid15028824">{{cite journal |author=Neoptolemos JP, Stocken DD, Friess H, ''et al'' |title=A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer |journal=N. Engl. J. Med. |volume=350 |issue=12 |pages=1200–10 |year=2004 |pmid=15028824 |doi=10.1056/NEJMoa032295}}</ref>
 
===Criteria for Unresectability===
* Tumor larger than 5 cm
* Tumor invades adjacent tissue of organs (excluding duodenum)
* Encasement, stenosis, or occlusion of the celiac artery, celiac artery branches, and/or SMA.
* ''PV and/or SMV encasement (some centers will operate with venous invasion)''
* Hepatic metastases
* Distant metastases (i.e. non regional lymph nodes)
* Peritoneal carcinomatosis
 
References


==References==
==References==
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[[Category:Disease]]  [[Category:Types of cancer]]  [[Category:Mature chapter]]  [[Category:Primary care]]
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<references />
[[Category:Disease]]
[[Category:Types of cancer]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Surgery]]
[[Category:Gastroenterology]]

Latest revision as of 23:33, 29 July 2020

Pancreatic cancer Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sudarshana Datta, MD [2]

Overview

The mainstay of therapy for pancreatic cancer is surgery. The different surgical techniques that may be used for resectable pancreatic cancer include pancreaticoduodenectomy (Whipple Procedure), pylorus sparing Whipple procedure, distal pancreatectomy and total pancreatectomy. The method of surgical resection depends on the locally invasive characteristics and size of the neoplasm. The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on resection margins, probability of cure, age, and comorbidities. Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients. CA19-9 levels help predict the likelihood of complete resection, the prognosis of patients with resectable disease and the presence of occult metastasis.

Surgery

  • In patients with pancreatic cancer, surgery is the primary modality of treatment.
  • Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications.
  • The benefits, risks and complications are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:[1][2][3]
    • Locally invasive characteristics of the neoplasm
    • Size

Criteria for Unresectability

Surgical methods of curative resection include:

The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:[4][5][6][7][8]

Pancreaticoduodenectomy (Whipple Procedure)

Various features of Whipple procedure are as follows:[19][6][39][40][41][42][43][44]

Pylorus sparing Whipple procedure

Distal Pancreatectomy

Total Pancreatectomy

Various features of total pancreatectomy are as follows:[48][73][74][75][76][77][78][79]

Lymphadnectomy

CA 19-9 level

  • Elevated levels of CA19-9 can help in the following ways:[87]
    • Predict the likelihood of complete resection
    • Predict prognosis of patients with resectable pancreatic cancer
    • Predict the presence of occult metastasis
  • CA19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.

 Palliative Therapy

Palliative therapy in patients with pancreatic cancer mainly involves the management of symptoms arising as a result of complications of surgery:[88][89][90][91][92][93][94][95]

Pain:

Jaundice:

  • Types of stents:
    • Metal- costly, longer lifespan
    • Plastic- cheaper, need replacement every three months

Duodenal obstruction

References

  1. ↑ 1.0 1.1 Ryan DP, Hong TS, Bardeesy N (2014). "Pancreatic adenocarcinoma". N. Engl. J. Med. 371 (11): 1039–49. doi:10.1056/NEJMra1404198. PMID 25207767.
  2. ↑ Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M (2017). "Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma". Ann. Surg. 265 (1): 185–191. doi:10.1097/SLA.0000000000001763. PMID 27163957.
  3. ↑ Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS (2007). "Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database". Cancer. 110 (4): 738–44. doi:10.1002/cncr.22852. PMID 17580363.
  4. ↑ Fonseca AL, Fleming JB (2017). "Surgery for pancreatic cancer: critical radiologic findings for clinical decision making". Abdom Radiol (NY). doi:10.1007/s00261-017-1332-z. PMID 28948329.
  5. ↑ Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM (2014). "Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association". Radiology. 270 (1): 248–60. doi:10.1148/radiol.13131184. PMID 24354378.
  6. ↑ 6.0 6.1 6.2 Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH (2016). "Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline". J. Clin. Oncol. 34 (21): 2541–56. doi:10.1200/JCO.2016.67.5553. PMID 27247221.
  7. ↑ 7.0 7.1 Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A (2013). "Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines". Pancreas. 42 (6): 1004–10. doi:10.1097/MPA.0b013e31827b2d7c. PMID 23532000.
  8. ↑ Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, Javle MM, Eads JR, Allen P, Ko AH, Engebretson A, Herman JM, Strickler JH, Benson AB, Urba S, Yee NS (2016). "Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline". J. Clin. Oncol. 34 (22): 2654–68. doi:10.1200/JCO.2016.67.5561. PMID 27247216.
  9. ↑ Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T, Kim G, Noh K, Wallace MB (2007). "Vascular resection and reconstruction for pancreatic malignancy: a single center survival study". J. Gastrointest. Surg. 11 (9): 1168–74. doi:10.1007/s11605-007-0216-x. PMID 17632763.
  10. ↑ Donahue TR, Isacoff WH, Hines OJ, Tomlinson JS, Farrell JJ, Bhat YM, Garon E, Clerkin B, Reber HA (2011). "Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery". Arch Surg. 146 (7): 836–43. doi:10.1001/archsurg.2011.152. PMID 21768431.
  11. ↑ Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB (2004). "Pancreaticoduodenectomy with vascular resection: margin status and survival duration". J. Gastrointest. Surg. 8 (8): 935–49, discussion 949–50. doi:10.1016/j.gassur.2004.09.046. PMID 15585381.
  12. ↑ Martin RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA (2009). "Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes". Arch Surg. 144 (2): 154–9. doi:10.1001/archsurg.2008.547. PMID 19221327.
  13. ↑ Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE (2012). "The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database". Ann. Surg. Oncol. 19 (13): 4068–77. doi:10.1245/s10434-012-2585-y. PMID 22932857.
  14. ↑ Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB (1998). "Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head". Br J Surg. 85 (5): 611–7. doi:10.1046/j.1365-2168.1998.00641.x. PMID 9635805.
  15. ↑ Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB (1996). "Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group". Ann. Surg. 223 (2): 154–62. PMC 1235091. PMID 8597509.
  16. ↑ Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T (2013). "Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma". J Surg Oncol. 107 (4): 414–21. doi:10.1002/jso.23229. PMID 22886567.
  17. ↑ Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M (2009). "Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma?". Ann. Surg. Oncol. 16 (4): 817–25. doi:10.1245/s10434-008-0281-8. PMID 19156463.
  18. ↑ Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J (2011). "Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis". Ann. Surg. 254 (6): 882–93. doi:10.1097/SLA.0b013e31823ac299. PMID 22064622.
  19. ↑ 19.0 19.1 Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D (2015). "Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up". Ann. Oncol. 26 Suppl 5: v56–68. doi:10.1093/annonc/mdv295. PMID 26314780.
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  21. ↑ Evans DB, George B, Tsai S (2015). "Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy". Ann. Surg. Oncol. 22 (11): 3409–13. doi:10.1245/s10434-015-4649-2. PMID 26122369.
  22. ↑ Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ (2015). "Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer". Br J Surg. 102 (3): 182–93. doi:10.1002/bjs.9716. PMID 25524417.
  23. ↑ Pancreatic Cancer - Johns Hopkins Medicine: Surgical Treatment of Pancreatic Cancer
  24. ↑ Krzyzanowska MK, Weeks JC, Earle CC (2003). "Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness". J. Clin. Oncol. 21 (18): 3409–14. doi:10.1200/JCO.2003.03.007. PMID 12972517.
  25. ↑ Aristu J, Cañón R, Pardo F, Martínez-Monge R, Martin-Algarra S, Manuel Ordoñez J, Villafranca E, Moreno M, Cambeiro M, Azinovic I (2003). "Surgical resection after preoperative chemoradiotherapy benefits selected patients with unresectable pancreatic cancer". Am. J. Clin. Oncol. 26 (1): 30–6. PMID 12576921.
  26. ↑ Turrini O, Viret F, Moureau-Zabotto L, Guiramand J, Moutardier V, Lelong B, Giovannini M, Delpero JR (2009). "Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma". Eur J Surg Oncol. 35 (12): 1306–11. doi:10.1016/j.ejso.2009.06.005. PMID 19576722.
  27. ↑ Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz M (2017). "Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update". J. Clin. Oncol. 35 (20): 2324–2328. doi:10.1200/JCO.2017.72.4948. PMID 28398845. Vancouver style error: initials (help)
  28. ↑ Gurusamy KS, Kumar S, Davidson BR, Fusai G (2014). "Resection versus other treatments for locally advanced pancreatic cancer". Cochrane Database Syst Rev (2): CD010244. doi:10.1002/14651858.CD010244.pub2. PMID 24578248.
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  59. ↑ Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL (2003). "Surgeon volume and operative mortality in the United States". N. Engl. J. Med. 349 (22): 2117–27. doi:10.1056/NEJMsa035205. PMID 14645640.
  60. ↑ Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA (2011). "Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery". Br J Surg. 98 (4): 485–94. doi:10.1002/bjs.7413. PMID 21500187.
  61. ↑ Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR (2007). "Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery". Surgery. 142 (3): 313–8. doi:10.1016/j.surg.2007.04.022. PMID 17723881.
  62. ↑ Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007). "Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)". Surgery. 142 (5): 761–8. doi:10.1016/j.surg.2007.05.005. PMID 17981197.
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