Adenocarcinoma of the pancreas remains a lethal malignancy: The majority of patients with pancreatic cancer continue to present with advanced disease and die within a year of diagnosis. Despite this grim fact, some progress has been made over the past decade, particularly in the surgical management of patients with resectable and advanced disease. This well-constructed review by Drs. Ahrendt and Pitt succinctly details the advances that have been made and highlights many of the unresolved issues.
Surgery remains the only potentially curative option for the minority of patients who present with localized disease. Although pancreatectomy was previously associated with significant perioperative morbidity and mortality, advances in patient selection, surgical technique, and perioperative care have led to a decline in associated morbidity and mortality. However, some controversy persists as to appropriate preoperative staging, optimal operative technique, and the role, if any, of adjuvant or neoadjuvant multimodality therapies in these patients.
At its most basic, the aim of any staging modality is to facilitate delivery of appropriate therapy and enable a determination to be made regarding prognosis. In diseases for which there is no universally accepted "standard of care," the role of a particular staging modality is often controversial. For example, the authors have clearly stated their view that laparoscopic staging is not indicated in patients with unresectable disease who would benefit from operative palliation. Although we agree with this opinion, I suspect that we may differ in regard to the degree with which we believe that operative intervention is warranted, especially for potential gastric outlet obstruction.
As the authors note, we previously reported a prospective, nonrandomized series in 155 patients who underwent laparoscopic staging alone and noted a need for subsequent surgical bypass in 3%. We recently updated this work and compared patients undergoing laparoscopic staging alone to a cohort of similar patients who received a prophylactic gastric bypass. This study suggested that the rate of reintervention was similar whether or not a prophylactic bypass was performed. In addition, prophylactic bypass appeared to have a higher early cost in morbidity and mortality. Because these results disagree somewhat with those of the recent randomized trial published by Lillemoe and colleagues, this issue warrants further examination.
In regard to the type of operative procedure, I suspect that a pylorus-sparing pancreatectomy is not the standard approach adopted by many pancreatic surgeons in this country for patients with adenocarcinoma of the pancreas. At Memorial Sloan-Kettering Cancer Center, the "classic" Whipple procedure accounts for over 90% of the pancreaticoduodenectomies performed. This is due, in part, to concern about the nodal clearance obtained and the lack of a defined benefit associated with preserving the pylorus in this patient population.