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Surgical Management of Pancreatic Cancer

Surgical Management of Pancreatic Cancer

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.

Staging Controversies

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%.[1] We recently updated this work and
compared patients undergoing laparoscopic staging alone to a cohort of similar
patients who received a prophylactic gastric bypass.[2] 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.[3]

Surgical Dilemmas

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.

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