• Surgical resection is the definitive treatment of pancreatic cancer with a goal of achieving negative (R0) margins of resection
  • Upfront surgery is the standard of care for resectable tumors
• Must be performed 4-8 weeks after neoadjuvant therapy
  • Resection after >8 weeks following neoadjuvant therapy may be difficult due to radiation-induced fibrosis
• Decisions regarding resectability status should involve multidisciplinary consultation

Resectability Status Criteria

Locally and Clearly Resectable Tumors

• Distant metastases absent
• Evidence of superior mesenteric vein (SMV) or portal vein (PV) invasion absent on radiographic exam or ≤180 degrees encasement without vein distortion
• Surrounding structures of the celiac axis, common hepatic artery (CHA), and superior mesenteric artery (SMA) clear

Borderline Resectable Tumors

• Distant metastases absent
• Head/uncinate process: CHA encasement without extension to celiac axis or hepatic artery bifurcation allowing for complete resection and reconstruction; ≤180 degrees contact with SMA
• Body/tail: ≤180 degrees contact with the celiac axis or >180 degrees contact with celiac axis without involvement of the aorta and with intact and uninvolved gastroduodenal artery
• >180 degrees contact of tumor with SMV/PV or ≤180 degrees contact with SMV or PV venous involvement with distortion or narrowing, or venous occlusion with patent proximal and distal vessel allowing venous reconstruction
• Solid tumor contact with the inferior vena cava (IVC)

Locally Advanced Tumors

• Head/uncinate process: Distant metastases present; >180 degrees SMA encasement or celiac axis abutment; unreconstructable SMV/PV occlusion
• Body/tail: Distant metastases present; >180 degrees SMA or celiac axis encasement; unreconstructable SMV/PV occlusion; tumor contact with the celiac axis and aortic involvement
• All: Metastases to lymph node beyond the field of resection

Surgical Procedures

Pancreatoduodenectomy (Whipple Technique)

• Procedure of choice for pancreatic head and uncinate tumors
• Preserves the distal stomach and pylorus
  • Further studies are suggested to prove the benefit of pylorus-preserving pancreatoduodenectomy as an alternative to the classic pancreatoduodenectomy
  • Extended lymphadenectomy does not increase overall survival of patients undergoing Whipple technique

Distal Pancreatectomy with En-bloc Splenectomy

• Procedure of choice for pancreatic body and tail tumors
• Reports have shown a tumor clearance of 72-91% after distal pancreatectomy, with good long-term survival rates comparable to that of total resection for localized tumors
• Minimally invasive distal pancreatectomy (MIDP) may be considered for benign and low-grade malignant tumors
  • Shown to have equivalent complication rates compared with open distal pancreatectomy and is associated with shorter hospital stay and reduced blood loss

Total Pancreatectomy

• The only curative treatment option for pancreatic cancer patients with stage I/II disease
• Indicated for multifocal tumors and tumors with borders that cannot be delineated with other techniques
• Involves removal of the entire pancreas, part of the small intestine, portion of the stomach, common bile duct, gall bladder, spleen and nearby lymph nodes 
• Not recommended for patients ≥75 yr due to possible comorbidities