Costs of laparoscopic and open liver and pancreatic resection:A systematic review

AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed.

Clinical and economic consequences of pancreatic fistula after elective pancreatic resection

BACKGROUND:Postoperative pancreatic fistula is the main cause of morbidity after pancreatic resection.This study aimed to quantify the clinical and economic consequences of pancreatic fistula in a medium-volume pancreatic surgery center.METHODS:Hospital records from patients who had undergone elective pancreatic resection in our department were identified.Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula(ISGPF).The consequences of pancreatic fistula were determined by treatment cost,hospital stay,and out-patient follow-up until the pancreatic fistula was completely healed.All costs of the treatment are calculated in Euros.The cost increase index was calculated for pancreatic fistula of grades A,B,and C as multiples of the total cost for the no fistula group.RESULTS:In 54 months,102 patients underwent elective pancreatic resections.Forty patients(39.2%) developed pancreatic fistula,and 54 patients(52.9%) had one or more complications.The median length of hospital stay for the no fistula,grades A,B,and C fistula groups was 12.5,14,20,and 59 days,respectively.The hospital stay of patients with fistula of grades B and C was significantly longer than that of patients with no fistula(P【0.001).The median total cost of the treatment was 4952,4679,8239,and 30 820 Euros in the no fistula,grades A,B,and C fistula groups,respectively.CONCLUSIONS:The grading recommended by the ISGPF is useful for comparing the clinical severity of fistula and for analyzing the clinical and economic consequences of pancreatic fistula.Pancreatic fistula prolongs the hospital stay and increases the cost of treatment in proportion to the severity of the fistula.

Intra-abdominal drainage following pancreatic resection:A systematic review

AIM: To study all the aspects of drain management in pancreatic surgery.METHODS: We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials,EMBASE,Web of Science,and Pub Med(MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management,such as drain vs no drain,selective drain use,early vs late drain extraction,and the use of different types of drains. RESULTS: A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains,studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intraabdominal drains. With respect to the timing of drain removal,all of the included studies reported superior results with early drain removal. Regarding the varioustypes of drains,there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection. CONCLUSION: The prophylactic use of drains remains controversial. When drains are used,early removal is recommended. Further trials comparing types of drains are ongoing.

Tight glycemic control using an artificial endocrine pancreas may play an important role in preventing infection after pancreatic resection

It is well known that perioperative hyperglycemia is the main cause of infectious complications after surgery.To improve perioperative glycemic control,we wish to highlight and comment on an interesting paper published recently by the Annals of Surgery entitled:"Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy(PD)" by Eshuis et al.The authors concluded that early postoperative glucose levels more than 140 mg/dL was significantly associated with complications after PD.Since we recommend that perioperative tight glycemic control(TGC) is an effective method to prevent postoperative complications including surgical site infection after distal,proximal,and total pancreatic resection,we support strongly this conclusion drawn in this article.However,if early postoperative glucose control in patients undergoing PD was administrated by conventional method such as sliding scale approach as described in this article,it is difficult to maintain TGC.Therefore,we introduce a novel perioperative glycemic control using an artificial endocrine pancreas against pancreatogenic diabetes after pancreatic resection including PD.

Polysorb^R(an absorbable lactomer) staples, a safe closure technique for distal pancreatic resection

AIM:To investigate twenty-year experience evaluated the use of the PolysorbR(an absorbable lactomer)staples for distal pancreatic resection.METHODS:The data on 150 patients[92 men,58women,mean age 52(24-72)years]who underwent distal pancreatectomy(DP)in the last 20 years were collected prospectively from an electronic database.The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography,sonography,computed tomography and/or magnetic resonance imaging.The indications for DP were focal pancreatic necrosis,spontaneous pancreatic fistulas,abscesses,pseudocysts,segmental chronic obstructive pancreatitis in the tail,traumatic disruption,and benign(cystadenomas,insulinomas,or glucagonomas)or malignant tumours.The distal resections were performed without splenectomy in 29 of the 150 patients(19%).In the event of splenectomy,the splenic artery and vein were individually ligated,the TA-55 Auto Suture stapler,loaded with Premium PolysorbR 55 staples(5.5mm),was placed across the gland,and the trigger was pulled,the action of which produced two staggered absorbable suture lines.The gland distal to the stapler wasthen amputated with a scalpel on the TA-55 stapler and the two rows of staples were left in the proximal pancreatic stump.After the distal resection,a drainage tube was inserted into the pancreatic bed.RESULTS:The average duration of the operation was150 min(range:90-210 min)and no transfusion was indicated during the operation.After DP in one patient a type B fistula was diagnosed,which was treated successfully by conservative treatment comprising of 12-d octreotide medication(3×0.1 mg/d)and jejunal feeding.The incidence of postoperative pancreatic fistula was therefore0.6%.Another 2 patients suffered postoperative pancreatitis,which was also conservatively treated.Reoperations were performed in 2 patients on the first or second postoperative day,necessitated by bleeding from the retroperitoneal region.The morbidity was 3.3%(5 patients),but no mortality occurred in the postoperative period.Overall,the postoperative period was uneventful without any complications(pancreatic fistula,abscess,bleeding or wound infection)in 145 patients.The length of the postoperative stay ranged between 8 and 16 d.For the 145 patients who had no any postoperative complications,the hospital stay was 8 or 9 d.No mortality occurred in the follow-up period(6 or 12 mo postoperatively);but 6 mo after surgery one patient suffered a pseudocyst following recurrent pancreatitis and was treated with cystojejunostomy.CONCLUSION:Our clinical results demonstrated that the application of absorbable lactomer staples for distal pancreatic resection is a safe alternative to the standard closure technique.

Severe morbidity after pancreatectomy is accurately pre dicte d by preoperative pancreatic resection score(PREPARE): A prospective validation analysis from a medium-volume center

Background: Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection(PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. Methods: A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity(Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay(LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables(not included in PREPARE) was also tested. Results: Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in lowrisk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively( P = 0.023). The accuracy was 72%(Hosmer–Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve(AUC) of 0.736(95% CI: 0.586–0.887; P = 0.007) and 0.712(95% CI: 0.555–0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases(9, 11 and 15 days in low-, intermediate-and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. Conclusions: PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.

Preoperative pancreatic resection score:a preliminary prospective validation from Spain

To the Editor：We read with outstanding interest the article by Celik et al. It is the first external description of the Hamburg＇s preoperative pancreatic resection （PREPARE） score since it was published in 2014 by Uzunoglu et al. According to the latter authors, it is necessary to stratify risk of major morbidity and mortality before performing a pancreatic resection, and PREPARE score is a simple index, validated in a multicenter cohort of patients undergoing this group of technically demanding procedures.

Preoperative 3D reconstruction and fluorescent indocyanine green for laparoscopic duodenum preserving pancreatic head resection:A case report

BACKGROUND Duodenum-preserving pancreatic head resection(DPPHR)is the choice of surgery for benign or low-grade malignant tumors of the pancreatic head.Laparoscopic DPPHR(LDPPHR)procedure can be improved by preoperative 3D model reconstruction and the use of intravenous indocyanine green fluorescent before surgery for real-time navigation with fluorescent display to guide the surgical dissection and prevention of from injury to vessels and biliary tract.CASE SUMMARY Here we report the successful short-and long-term outcomes after one year following LDPPHR for a 60-year lady who had an uneventful recovery and was discharged home one week after the surgery.CONCLUSION There was no bile leakage or pancreatic leakage or delayed gastric emptying.The histopathology report showed multiple cysts in the pancreatic head and localized pancreatic intraepithelial tumor lesions.The resected margin was free of tumor.

Quality of life after pancreatic surgery

BACKGROUND Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas.Increasing attention has been paid to changes in quality of life(QOL)after pancreatic surgery.AIM To summarize and analyze current research results on QOL after pancreatic surgery.METHODS A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Relevant studies were identified by screening the references of retrieved articles.Studies on patients’QOL after pancreatic surgery published after January 1,2012,were included.These included prospective and retrospective studies on patients'QOL after several types of pancreatic surgeries.The results of these primary studies were summarized inductively.RESULTS A total of 45 articles were included in the study,of which 13 were related to pancreaticoduodenectomy(PD),seven to duodenum-preserving pancreatic head resection(DPPHR),nine to distal pancreatectomy(DP),two to central pancre-atectomy(CP),and 14 to total pancreatectomy(TP).Some studies showed that 3-6 months were needed for QOL recovery after PD,whereas others showed that 6-12 months was more accurate.Although TP and PD had similar influences on QOL,patients needed longer to recover to preoperative or baseline levels after TP.The QOL was better after DPPHR than PD.However,the superiority of the QOL between patients who underwent CP and PD remains controversial.The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL.Minimally invasive surgery could improve patients’QOL in the early Core Tip:This review summarizes and analyzes current research results on quality of life(QOL)after pancreatic surgery.The article covers the discussion and analysis of the QOL of various pancreatic surgeries.Which kind of surgical procedure has better QOL is controversial.The long-term benefits on QOL of minimally invasive surgery over open surgery are contro-INTRODUCTION The pancreas,located in the retroperitoneum,is a glandular organ with endocrine and exocrine functions.It can be divided into four main parts:Head,neck,body,and tail.Pancreatic surgery can be divided into pancreaticoduoden-ectomy(PD),duodenum-preserving pancreatic head resection(DPPHR),distal pancreatectomy(DP),central pancre-atectomy(CP),and total pancreatectomy(TP).Pancreatic surgery is challenging due to the organ’s complex anatomical structure,peripheral vascularity,and intractable postoperative complications.Following the standardization of surgical steps and improvements in relevant medical techniques and surgical instruments,the safety of pancreatic surgery has significantly improved.Perioperative morbidity,mortality,and other related indicators have become more acceptable.However,owing to the organ’s essential role in digestion,absorption,and blood glucose regulation,changes in the quality of life(QOL)of patients after pancreatic surgery have attracted the attention of surgeons.More patients with non-malignant pancreatic diseases are willing to undergo surgical treatment because of the acceptable safety.In this case,from the perspective of the patient postoperatively,the significance of rehabilitation reflects the traditional perioperative outcome and QOL[1].The QOL is a new concept that extends beyond health.Although there is no consensus on its conception[2],we can consider it a multi-dimensional architecture that incorporates objective and individual subjective views of aspects of one’s physical,psychological,and social well-being[3-5].It includes evaluating physical health,and many subscales,such as emotion,job,culture,family,sociability,economy,cognition,happiness,sex,and some symptoms[6].Since people have realized the importance of QOL,many QOL scales have emerged,including the European Organization for Research and Treatment of Cancer QLQ-C30,European Quality of Life 5-dimension,36-item Short,etc.However,it is challenging to follow up on patients’QOL once they are discharged from the hospital.Consequently,most relevant studies had small sample sizes or lacked long-term follow-up results.Moreover,a summary of studies on QOL after pancreatic surgery is lacking.This study assessed the QOL in patients who underwent PD,DPPHR,DP,CP and TP.We conducted this study to describe the existing findings on the QOL after pancreatic surgery to make it easier for surgeons and patients to decide on a surgical approach.In addition,we attempted to identify controversial results to encourage further targeted research.

Influence of the body mass index on postoperative outcome and long-term survival after pancreatic resections in patients with underlying malignancy

Background:While the long-term survival rate among patients with pancreatic and periampullary carcinomas remains low,it can be influenced by various factors.The purpose of this retrospective study was to investigate the effects of body mass index(BMI)on postoperative complications and patient survival after pancreatic resections for underlying malignancy over a 20-year observation period.Methods:We analyzed 1,384 patients,918 patients with pancreatic ductal adenocarcinoma(PDAC)(66.3%),229 patients with distal cholangiocarcinoma(16.5%),206 ampullary carcinoma patients(14.8%),and 31 duodenal carcinoma patients(2.2%).Patients were classified into four groups(group 1<18.5;group 2,18.5–25.0;group 3,25.1–30.0;group 4>30.0)according to their BMI(kg/m2).We analyzed differences in postoperative complications,postoperative length of hospital stays,reoperations,postoperative mortality and survival rate among the groups.Results:Within a mean observation period of 687.7[2–8,500]days,735(53.1%)patients died.There were important differences in postoperative complications(group 1,16.2%;group 2,20.3%;group 3,27.2%,group 4,41.6%)with the type of postoperative complications also varying between the groups.Overall 1-,5-,10-and 15-year survival rates were 66.4%,25.5%,17.9%,and 12.1%,respectively,with survival rates varying amongst the four groups.Conclusions:Patients with a BMI between 18.5 and 30 show better postoperative outcomes,regarding complications,hospitalization duration,and reoperation rates than underweight or obese patients.Short-term survival depends strongly on postoperative complications while patients with a higher BMI show better long-term survival rates.

Vascular resections in minimally invasive surgery for pancreatic cancer

Pancreatic ductal adenocarcinoma(PDAC)is characterised by poor oncological outcome and is the seventh cause of cancer-related deaths worldwide.With the advances in surgical technology,oncological treatment,and critical care,extended pancreatic resections including vascular resections have become more frequently performed in specialised centres.Furthermore,the boundaries of resectability continue to be pushed in order to achieve a potentially curative approach in selected patients in combination with neoadjuvant and adjuvant treatment strategies.This review gives an overview on the current state of venous and arterial resections in PDAC surgery with particular attention given to the minimally invasive approach.

Experience of limited pancreatic head resection for management of branch duct intraductal papillary mucinous neoplasm in a single center

AIM: To share our surgical experience and the outcome of limited pancreatic head resection for the management of branch duct intraductal papillary mucinous neoplasm (IPMN). METHODS: Between May 2005 and February 2008, nine limited pancreatic head resections (LPHR) were performed for IPMN of the pancreatic head. We reviewed the nine patients, retrospectively. RESULTS: Tumor was located in the uncinate process of the pancreas in all nine patients. Three patients had stents inserted in the main pancreatic duct due to injury. The mean size of tumor was 28.4 mm. Postoperative complications were found in f ive patients: 3 pancreatic leakages, a pancreatitis, and a duodenal stricture. Pancreatic leakages were improved by external drainage. No perioperative mortality was observed and all patients are recorded alive during the mean follow-up period of 17.2 mo. CONCLUSION: In selected patients after careful evaluation, LPHR can be used for the treatment of branch duct type IPMN. In order to avoid pancreatic ductal injury, preand intra-operative defi nite localization and careful operative techniques are required.

Xanthogranulomatous pancreatitis treated by duodenum-preserving pancreatic head resection

BACKGROUND:Xanthogranulomatosis is an idiopathic,rare process in which lipid-laden histiocytes are deposited at various locations in the body.We present two cases who were treated by duodenum-preserving pancreatic head resection and eventually diagnosed as having xanthogranulomatous pancreatitis. METHODS:A 30-year-old caucasian man was admitted to our clinic for vague abdominal pain and epigastric dullness. Magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography suggested the existence of chronic pancreatitis.Another 34-year-old caucasian woman was admitted to our clinic because of right upper quadrant pain. Magnetic resonance cholangiopancreatography demonstrated a dilatation and stone of the main pancreatic duct.Based on a diagnosis of chronic pancreatitis,pancreatic head resection was planned and a laparotomy was performed in both of cases. RESULTS:In both cases,duodenum-preserving pancreatic head resection was performed.Macroscopic and microscopic findings revealed xanthogranulomatous inflammation,which led to a diagnosis of xanthogranulomatous pancreatitis. CONCLUSION:Although this type of pancreatitis is extremely rare,it is important to keep it in mind for a differential diagnosis because it may simulate chronic pancreatitis or a malignant tumor on imaging.

Comprehensive multimodal management of borderline resectable pancreatic cancer:Current status and progress

Borderline resectable pancreatic cancer(BRPC)is a complex clinical entity with specific biological features.Criteria for resectability need to be assessed in combination with tumor anatomy and oncology.Neoadjuvant therapy(NAT)for BRPC patients is associated with additional survival benefits.Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT.More attention to management standards during NAT,including biliary drainage and nutritional support,is needed.Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period,including NAT responsiveness and the selection of surgical timing.

A case of chronic pancreatitis treated by laparoscopic duodenum-preserving pancreatic head resection

Pancreaticoduodenectomy(PD) has long been used for chronic pancreatitis(CP), but greatly affects the postoperative quality of life. A new procedure called duodenum-preserving pancreatic head resection(DPPHR) has been introduced, and has little effect on the structure and function of the digestive system. With the development of minimally invasive surgical techniques, treatment of CP can be performed with laparoscopic DPPHR(LDPPHR). We present a case of CP that was successfully treated with LDPPHR. The postoperative pathological diagnosis was pancreatitis, demonstrating the feasibility of LDPPHR. We recommend this minimally invasive surgical method as preferred treatment for CP.

Pancreatoduodenectomy with Simultaneous Venous Resection for Advanced Ductal Pancreatic Head Cancer:A Case Control Study

Introduction: Surgical resection is the treatment of choice for pancreatic ductal adenocarcinoma (PDA). However, in case of venous tumor in-volvement, carcinomas are classified as borderline resectable and their preferential therapy remains controversial. The purpose of this study is to analyze the effectiveness of the surgical approach with simultaneous venous resection regarding perioperative outcome and long-term survival. Patients and methods: All patients that underwent pancreatoduodenectomy (PD) for PDA at our institution between 02/2002 and 12/2016 were analyzed retrospectively. A matched-pair analysis between patients that underwent PD with simultaneous venous resection (PDVR) and standard PD was performed to compare perioperative parameters, survival and factors relevant to long-term survival. Results: The study included 142 patients: 71 underwent PDVR and 71 underwent standard PD. Venous tumor infiltration could histopathologically be confirmed in 21 patients (29.58%). PDVR wasn’t associated with a higher rate of postoperative complications (56.34% for both groups), severe postoperative complications (28.17% vs. 23.94%) and mortality (5.63% vs. 9.86%) compared to standard PD. Median overall survival of both groups was 17 months (95% CI 10.89 - 23.11), without statistical significance between the two groups (PD 22 months, 95% CI 16.02 - 27.99 vs. PDVR 16 months, 95% CI 9.96 - 22.04, p = 0.087). Parameters associated with overall survival were his-topathologically proven venous tumor infiltration, the lymph node status and the necessity of postoperative blood transfusions. Conclusion: PDVR is justified, because peri- and post-operative morbidity and mortality, as well as long-term survival, are comparable to standard PD. Even in case of postoperatively histopathologically confirmed venous tumor infiltration, patients benefit over palliative treatment.

Pancreatic cancer: Advances in treatment

Pancreatic cancer is a leading cause of cancer mortality and the incidence of this disease is expected to continue increasing.While patients with pancreatic cancer have traditionally faced a dismal prognosis,over the past several years various advances in diagnosis and treatment have begun to positively impact this disease.Identification of effective combinations of existing chemotherapeutic agents,such as the FOLFIRINOX and the gemcitabine+nab-paclitaxel regimen,has improved survival for selected patients although concerns regarding their toxicity profiles remain.A better understanding of pancreatic carcinogenesis has identified several pre-malignant precursor lesions,such as pancreatic intraepithelial neoplasias,intraductal papillary mucinous neoplasms,and cystic neoplasms.Imaging technology has also evolved dramatically so as to allow early detection of these lesions and thereby facilitate earlier management.Surgery remains a cornerstone of treatment for patients with resectable pancreatic tumors,and advances in surgical technique have allowed patients to undergo resection with decreasing perioperative morbidity and mortality.Surgery has also become feasible in selected patients with borderline resectable tumors as a result of neoadjuvant therapy.Furthermore,pancreatectomy involving vascular reconstruction and pancreatectomy with minimally invasive techniques have demonstrated safety without significantly compromising oncologic outcomes.Lastly,a deeper understanding of molecular aberrations contributing to the development of pancreatic cancer shows promise for future development of more targeted and safe therapeutic agents.

Resection of the uncinate process of the pancreas due to a ganglioneuroma

A 33-year-old woman who presented with epigastric discomfort and diarrhea underwent an abdominal ultrasound(US).This investigation and subsequent contrastenhanced computed tomography,magnetic resonance imaging and endoscopic US with fine needle aspiration (FNA)revealed a 40 mm well-circumscribed mass in the uncinate process of the pancreas.Findings were suggestive of a mucinous or solid-cystic pseudopapillary tumor of the pancreas,although other lesions such as a nonfunctioning neuroendocrine tumor could not be ruled out.FNA samples were negative for malignant cells,but of limited value due to poor cellularity.It was decided to surgically remove the tumor because malignancy could not be discounted.Multiple intraoperative biopsies were suggestive of mesenchymal tumor and consequently a conservative resection(uncinatectomy)was performed. The postoperative course was uneventful.The definitive diagnosis was ganglioneuroma.Immunocytochemistry showed positive staining with vimentin,S-100 protein, neurofilament and neuron-specific enolase.Ganglioneuroma is a rare benign tumor that can also present as a pancreatic tumor.Uncinatectomy is feasible,safe and a good surgical technique for the treatment of nonmalignant tumors located in the uncinate process of the pancreas.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diag- nostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Emerging concepts in the management of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is characterised by poor oncological outcomes with curative treatment only possible for a minority.Symptoms are dependent on the stage of the disease and location within the pancreas with constitutional decline often prominent.Patients require biochemical investigations and accurate imaging with CT to determine stage of disease and local resectability.CT-PET and endoscopic ultrasound are increasingly used preoperatively.Surgery remains the cornerstone of curative management and can be performed using minimally invasive approaches.Vascular resection and combination treatment with chemoradiotherapy are also utilised for suitable patients.Perioperative outcomes may be optimised using enhanced recovery pathways.Quality standards have been defined for individual clinicians and units to benchmark their clinical outcomes.The developments described hold promise in improving outcomes from pancreatic ductal adenocarcinoma.