• Ampullary carcinoma
• Distal cholangiocarcinoma
• Duodenal carcinoma
• Pancreatic head carcinoma
• Pancreatoduodenectomy

• Adenocarcinoma/surgery
• Ampulla of Vater/surgery
• Common Bile Duct Neoplasms/surgery
• Duodenal Neoplasms/surgery
• Humans
• Pancreatic Neoplasms/diagnosis
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy

• Adenocarcinoma/mortality
• Adenocarcinoma/surgery
• Adult
• Ampulla of Vater/surgery
• Blood Loss, Surgical
• Common Bile Duct Neoplasms/mortality
• Common Bile Duct Neoplasms/surgery
• Confidence Intervals
• Gastric Emptying
• Humans
• Kaplan-Meier Estimate
• Lymph Node Excision/methods
• Lymph Node Excision/mortality
• Margins of Excision
• Operative Time
• Pancreatic Fistula/etiology
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/methods
• Postoperative Complications/etiology
• Postoperative Hemorrhage/etiology
• Randomized Controlled Trials as Topic

Digitalization is a disruptive technology that changes the way we deliver diagnostic procedures and treatments in medicine. Different stakeholders have varying interests in and expectations of the digitalization of modern medicine. Many recent digital advances in the medical field, such as the implementation of electronic health records, telemedical services, and mobile health apps, are increasingly used by medical professionals and patients. During the current pandemic outbreak of a novel coronavirus-caused respiratory disease (COVID-19), many modern information and communication technologies (ICT) have been used to overcome the physical barriers and limitations caused by government-issued curfews and workforce shortages. Therefore, the COVID-19 pandemic has led to a surge in the usage of modern ICT in medicine. At the same time, the eHealth literacy of physicians working with these technologies has probably not improved since our study.

This paper describes a representative cohort of German physicians before the COVID-19 pandemic and their eHealth literacy and attitude towards modern ICT.

A structured, self-developed questionnaire about user behavior and attitudes towards eHealth applications was administered to a representative cohort of 93 German physicians.

Of the 93 German physicians who participated in the study, 97% (90/93) use a mobile phone. Medical apps are used by 42% (39/93). Half of the surveyed physicians (47/93, 50%) use their private mobile phones for official purposes on a daily basis. Telemedicine is part of the daily routine for more than one-third (31/93, 33%) of all participants. More than 80% (76/93, 82%) of the trial participants state that their knowledge regarding the legal aspects and data safety of medical apps and cloud computing is insufficient.

Modern ICT is frequently used and mostly welcomed by German physicians. However, there is a tremendous lack of eHealth literacy and knowledge about the safe and secure implementation of these technologies in routine clinical practice.

• eHealth
• eHealth literacy
• electronic health
• health apps
• mobile health
• mobile health apps

Jaundice or preoperative cholestasis (PC) are typical symptoms of pancreatic masses. Approximately 50% of patients undergo preoperative biliary drainage (PBD) placement. PBD is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor. An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. For this, we examined the microbiological findings in routine series of patients.

To investigate the incidence and profile of biliary bacterial colonization in patients undergoing pancreatic head resections.

In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and PC was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. An analysis of the isolated species and resistograms was performed. Patients were categorized according to the presence or absence of PC (PC+/PC-) and PBD (PBD+/PBD-) into four groups. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.

BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n =120) than in PBD- (n = 30), P < 0.01. BB was present both in patients with PC and without PC: (PBD-/PC-: 18%, PBD-/PC+: 30%, PBD+/PC-: 88%, PBD+/PC+: 80%). BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor in multivariate analysis. In total, 357 pathogens (342 bacteria and 15 fungi) were detected. The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).

PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.

• Pancreatic surgery
• Bacteriobilia
• Antibiotic prophylaxis
• Cholestasis
• Cholangiopancreatography
• Endoscopic retrograde

• Anti-Bacterial Agents/therapeutic use
• Antibiotic Prophylaxis
• Bile/microbiology
• Bile Ducts/surgery
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholestasis/surgery
• Common Bile Duct Neoplasms/surgery
• Drainage/adverse effects
• Humans
• Jaundice, Obstructive/etiology
• Multivariate Analysis
• Pancreatectomy/adverse effects
• Pancreaticoduodenectomy/adverse effects
• Pancreatitis/surgery
• Retrospective Studies
• Risk Factors
• Surgical Wound Infection/microbiology
• Surgical Wound Infection/prevention & control

The aim of this study was to evaluate the accuracy of dual-time point in differentiating benign from malignant local recurrent lesions in pancreatic cancer.

Thirty-four patients with pancreatic cancer (22 males and 12 females, mean age: 58.3 ± 10.3) who presented with soft-tissue lesions at the operative bed. Early whole-body positron emission tomography/computed tomography (PET/CT) and delayed imaging on the abdomen were performed. The maximum standardized uptake value (SUVmax) of the initial image (SUVmax E) and the delayed image (SUVmax D) were determined. A Retention Index (RI) was also calculated. These indices were correlated with histopathology and follow-up as reference criteria.

No significant statistical difference in SUVmaxE was found between benign and malignant lesions, while SUVmaxD and RI of the malignant lesions (mean 8.6 ± 2.7 and 35.8 ± 18.3, respectively) were significantly higher than those of benign ones (mean 3.3 ± 1.4 and-6.2 ± 15.2, respectively) (P < 0.005). With SUVmaxD 4.9, malignancy could be predicted with the highest sensitivity (95.8%) and accuracy (94.1%) between the whole parameters. The estimated negative and positive predictive values (PPVs) were 90.0% and 95.8%, respectively. A cutoff point 16 for RI showed higher specificity and PPV (100% and 100%, respectively). Forty-seven total (11 benign and 36 malignant) lesions were identified. Increased SUVmax is noted on delayed images in most of malignant lesions, except for two that maintained stationary.

Dual-time-point 18F fluorodeoxyglucose-PET/CT seems to be a reliable additional method to differentiate between malignant and benign postoperative local soft-tissue lesions in patients with pancreatic cancer.

• Dual time point
• Retention Index
• fluorodeoxyglucose-positron emission tomography/computed tomography
• maximum standardized uptake value
• pancreatic lesion

Adjuvant chemotherapy (adCx) is an integral part of multimodal treatment in resected pancreatic ductal adenocarcinoma (PDAC) and is recommended by the German S3 guideline since 2007 in all patients. We aimed to investigate the impact of this guideline at our institution.

In 151 of 403 pancreatic resections performed histopathology revealed PDAC. Follow-up data were available from 143 patients (95%) representing our study group. The rate of recommended, initiated and fully completed adCx was analyzed for period 1 (09/2003–07/2007) and period 2 (08/2007–08/2014).

Our study group comprised 49 patients in period 1 and 94 patients in period 2. AdCx was recommended, initiated and completed in 42/49 (86%), 34/49 (69%) and 22/49 (45%) patients in period 1 and in 93/94 (99%), 78/94 (83%) and 49/94 (52%) patients in period 2, respectively. Only the increase in recommendations for adCx was statistically significant (p = 0.0024). Overall, only 50% (71/143) of patients fully completed the Cx protocol. Completed adCx resulted in a significantly longer (p = 0.0225) overall survival compared to patients with incomplete or without adCx. Multiple logistic regression revealed adCx (p = 0.0046) as independent factor of survival. The hazard ratio for fully completed adCx was 0.406 and for incomplete adCx 0.567.

Our results indicate a high acceptance of the S3-guidline recommendation for adCx in resected PDAC in a routine setting, which, however, is completed in only 50% of all patients. Fully completed adCx had the most powerful effect on improving overall survival.

•

After S3 guideline implementation only the increase in recommendations for adCx was statistically significant.

• Adjuvant chemotherapy
• Cohort study
• Guide-line compliance
• Long-term survival
• Resected pancreatic ductal adenocarcinoma

• Anti-tumor therapy
• Geldanamycin
• HSP90
• Pancreatic cancer
• Target therapy

• Gastrointestinal endoscopy
• Guideline gastrointestinal endoscopy
• Quality parameters

• CONKO-001
• DNA Index
• adjuvant therapy
• pancreatic adenocarcinoma
• tumor grading

The pancreas has a central function in digestion and glucose homeostasis. With regard to the exocrine function, which is responsible for the digestion and absorption of nutrients and vitamins, the most important disturbances of these physiological processes are based on deficiencies in enzyme production and secretion, either due to impaired excretion caused by obstruction of the pancreatic duct or due to loss of pancreatic tissue. Both conditions result in maldigestion, malabsorption, and malnutrition.

Systematic literature review.

Symptoms associated with pancreatic exocrine failure are gastrointestinal discomfort, steatorrhea, and weight loss. Pancreatic exocrine insufficiency caused by ductal obstruction occurs in chronic pancreatitis or with neoplasia of the pancreatic head. Loss of functional parenchyma can be caused either by chronic pancreatitis resulting in fibrotic replacement of the destroyed parenchyma or by a postoperative state of pancreatic resection.

In patients with chronic pancreatitis, a stage-adapted and timely therapy including conservative as well as surgical measures is essential to prevent functional deterioration and to preserve residual function. In the case of pancreatic resection for chronic pancreatitis, this can be achieved with modern organ-sparing surgery such as the duodenum-preserving pancreatic head resection. In patients requiring more extended pancreatic resections and even total duodenopancreatectomy, regardless of the underlying indication, adequate enzyme replacement and monitoring of the nutritional status is critical to prevent impairment of quality of life as well as detrimental malnutrition in the long term.

• Chronic pancreatitis
• Exocrine pancreatic insufficiency
• Pancreatic cancer
• Pancreatic maldigestion
• Pancreatic resection

This review focused in the perioperative management of patients with pancreatic cancer in order to improve the outcome of the disease. We consider that the most controversial points in pancreatic cancer management are jaundice management, vascular resection and neo-adjuvant therapy. Preoperative biliary drainage is recommended only in patients with severe jaundice, as it can lead to infectious cholangitis, pancreatitis and delay in resection, which can lead to tumor progression. The development of a phase III clinical trial is mandatory to clarify the role of neo-adjuvant radiochemotherapy in pancreatic adenocarcinoma. Venous resection does not adversely affect postoperative mortality and morbidity, therefore, the need for venous resection should not be a contraindication to surgical resection in selected patients. The data on arterial resection alone, or combined with vascular resection at the time of pancreatectomy are more heterogeneous, thus, patient age and comorbidity should be evaluated before a decision on operability is made. In patients undergoing R0 resection, arterial resection can also be performed.

• Pancreatic cancer
• Obstructive jaundice
• Preoperative drainage
• Neo-adjuvant therapy
• Vascular resection

• Adenocarcinoma/mortality
• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Chemoradiotherapy, Adjuvant
• Drainage
• Humans
• Neoadjuvant Therapy
• Pancreatectomy/adverse effects
• Pancreatectomy/mortality
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/mortality
• Perioperative Care
• Postoperative Complications/etiology
• Risk Assessment
• Risk Factors
• Treatment Outcome
• Vascular Surgical Procedures

In nonrandomized trials, neoadjuvant treatment was reported to prolong survival in patients with pancreatic cancer. As neoadjuvant chemoradiation is established for the treatment of rectal cancer we examined the value of neoadjuvant chemoradiotherapy in pancreatic cancer in a randomized phase II trial. Radiological staging defining resectability was basic information prior to randomization in contrast to adjuvant therapy trials resting on pathological staging.

Patients with resectable adenocarcinoma of the pancreatic head were randomized to primary surgery (Arm A) or neoadjuvant chemoradiotherapy followed by surgery (Arm B), which was followed by adjuvant chemotherapy in both arms. A total of 254 patients were required to detect a 4.33-month improvement in median overall survival (mOS).

The trial was stopped after 73 patients; 66 patients were eligible for analysis. Twenty nine of 33 allocated patients received chemoradiotherapy. Radiotherapy was completed in all patients. Chemotherapy was changed in 3 patients due to toxicity. Tumor resection was performed in 23 vs. 19 patients (A vs. B). The R0 resection rate was 48 % (A) and 52 % (B, P = 0.81) and (y)pN0 was 30 % (A) vs. 39 % (B, P = 0.44), respectively. Postoperative complications were comparable in both groups. mOS was 14.4 vs. 17.4 months (A vs. B; intention-to-treat analysis; P = 0.96). After tumor resection, mOS was 18.9 vs. 25.0 months (A vs. B; P = 0.79).

This worldwide first randomized trial for neoadjuvant chemoradiotherapy in pancreatic cancer showed that neoadjuvant chemoradiation is safe with respect to toxicity, perioperative morbidity, and mortality. Nevertheless, the trial was terminated early due to slow recruiting and the results were not significant. ISRCTN78805636; NCT00335543.

The online version of this article (doi: 10.1007/s00066-014-0737-7) contains supplementary material, which is available to authorized users.

AIM: To compare endoscopic retrograde cholangio-pancreatography (ERCP), intraductal ultrasound (IDUS), endosonography (EUS), endoscopic transpapillary forceps biopsies (ETP) and computed tomography (CT) with respect to diagnosing malignant bile duct strictures.

METHODS: A patient cohort with bile duct strictures of unknown etiology was examined by ERCP and IDUS, ETP, EUS, and CT. The sensitivity, specificity, and accuracy rates of the diagnostic procedures were calculated based on the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery. For each of the diagnostic measures, the sensitivity, specificity, and accuracy rates were calculated. In all cases, the gold standard was the histopathologic staging of specimens or long-term follow-up of at least 12 mo. A comparison of the accuracy rates between the localization of strictures was performed by using the Mann-Whitney U-test and the χ² test as appropriate. A comparison of the accuracy rates between the diagnostic procedures was performed by using the McNemar’s test. Differences were considered statistically significant if P < 0.05.

RESULTS: A total of 234 patients (127 males, 107 females, median age 64, range 20-90 years) with indeterminate bile duct strictures were included. A total of 161 patients underwent operative exploration; thus, a surgical histopathological correlation was available for those patients. A total of 113 patients had malignant disease proven by surgery; in 48 patients, benign disease was surgically found. In these patients, the decision for surgical exploration was made due to the suspicion of malignant disease in multimodal diagnostics (ERCP, CT, or EUS). Fifty patients had a benign diagnosis and were followed by a surveillance protocol with a follow-up of at least 12 mo; the median follow-up was 34 mo. Twenty-three patients had extended malignant disease, and thus were considered palliative. A comparison of the different diagnostic tools for detecting bile duct malignancy resulted in accuracy rates of 91% (ERCP/IDUS), 59% (ETP), 92% (IDUS + ETP), 74% (EUS), and 73% (CT), respectively. In the subgroup analysis, the accuracy rates (%, ERCP + IDUS/ETP/IDUS + ETP; EUS; CT) for each tumor entity were as follows: cholangiocellular carcinoma: 92%/74%/92%/70%/79%; pancreatic carcinoma: 90%/68%/90%/81%/76%; and ampullary carcinoma: 88%/90%/90%/76%/76%. The detection rate of malignancy by ERCP/IDUS was superior to ETP (91% vs 59%, P < 0.0001), EUS (91% vs 74%, P < 0.0001) and CT (91% vs 73%, P < 0.0001); EUS was comparable to CT (74% vs 73%, P = 0.649). When analyzing accuracy rates with regard to localization of the bile duct stenosis, the accuracy rate of EUS for proximal vs distal stenosis was significantly higher for distal stenosis (79% vs 57%, P < 0.0001).

CONCLUSION: ERCP/IDUS is superior to EUS and CT in providing accurate diagnoses of bile duct strictures of uncertain etiology. Multimodal diagnostics is recommended.

• Intraductal ultrasound
• Intraductal ultrasound
• Bile duct strictures
• Endosonography
• Computed tomography
• Malignancy

• Adult
• Aged
• Aged, 80 and over
• Biopsy
• Chi-Square Distribution
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/diagnosis
• Cholestasis/diagnostic imaging
• Cholestasis/etiology
• Cholestasis/pathology
• Cholestasis/surgery
• Constriction, Pathologic
• Digestive System Neoplasms/complications
• Digestive System Neoplasms/diagnosis
• Endosonography
• Female
• Humans
• Male
• Middle Aged
• Multimodal Imaging
• Predictive Value of Tests
• Prognosis
• Retrospective Studies
• Risk Factors
• Time Factors
• Tomography, X-Ray Computed
• Young Adult

• Carcinoma, Pancreatic Ductal/classification
• Carcinoma, Pancreatic Ductal/mortality
• Carcinoma, Pancreatic Ductal/pathology
• Carcinoma, Pancreatic Ductal/surgery
• Humans
• Lymph Node Excision
• Lymph Nodes/pathology
• Lymphatic Metastasis/pathology
• Neoplasm Invasiveness
• Neoplasm Staging
• Pancreas/pathology
• Pancreatic Neoplasms/classification
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy
• Prognosis
• Survival Rate

• adjuvant therapy
• gemcitabine
• rate of cure

Background: Genetic risk factors for sporadic pancreatic cancer are largely unknown but actually under high exposure. Findings of correlations between the AB0 blood group system (Chromosome 9q34,1—q34,2) and the risk of pancreatic cancer (PC) in patients from Asia, America and south Europe have already been published. So far it is unclear, whether this correlation between blood group an PC incidence can be found in German patients as well.

Methods: One hundred and sixty-six patients who underwent a resection of PC were evaluated in a period between 2000 and 2010. Blood group reference distribution for the German population is given as: 0: 41%; A: 43%; B: 11%; AB: 5%; Rhesus positive: 85%; Rhesus negative: 15%. Analyses were done using the non-parametric Chi²-test (p-value two sided; SPSS 19.0).

Results: Median age was 62 (34–82) years. Gender: female 73/44%; male: 93/56%. Observed blood group proportions: 0: 43 (25.9%)/A: 94 (56.6%)/B: 16 (9.6%)/AB: 13 (7.8%)/Rhesus positive: 131 (78.9%)/negative: 35 (21.1%). We detected a significant difference to the German reference distribution of the AB0 system (Chi² 19.34, df 3, p < 0.001). Rhesus factor has no impact on AB0-distribution (Chi² 4.13, df 3, p = 0.25), but differs significantly from reference distribution—probably due to initial AB0-variation (Chi² 4.82, df 1, p = 0.028). The odds ratio for blood group A is 2.01 and for blood group 0 is 0.5.

Conclusions: The incidence of PC in the German cohort is highly associated with the AB0-system as well. More patients with blood group A suffer from PC (p < 0.001) whereas blood group 0 was less frequent in patients with PC (p < 0.001). Thus, our findings support the results from other non-German surveys. The causal trigger points of this carcinogenesis correlation are still not known.

• ABO blood-group system
• determination
• genome
• pancreatic cancer
• risk factor

• Adult
• Algorithms
• Carcinoma, Pancreatic Ductal/diagnosis
• Carcinoma, Pancreatic Ductal/diagnostic imaging
• Diagnosis, Differential
• Humans
• Magnetic Resonance Imaging
• Middle Aged
• Pancreatic Neoplasms/diagnosis
• Pancreatitis, Chronic/diagnosis
• Pancreatitis, Chronic/diagnostic imaging
• Ultrasonography
• Weight Loss

• Aged
• Carcinoma, Pancreatic Ductal/mortality
• Carcinoma, Pancreatic Ductal/pathology
• Carcinoma, Pancreatic Ductal/surgery
• Cell Transformation, Neoplastic/pathology
• Cholangiopancreatography, Magnetic Resonance
• Diagnosis, Differential
• Disease Progression
• Disease-Free Survival
• Female
• Follow-Up Studies
• Guideline Adherence
• Humans
• Image Interpretation, Computer-Assisted
• Magnetic Resonance Imaging
• Male
• Middle Aged
• Neoplasm Invasiveness
• Neoplasm Staging
• Pancreas/pathology
• Pancreas/surgery
• Pancreatectomy/methods
• Pancreatic Ducts/pathology
• Pancreatic Ducts/surgery
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Precancerous Conditions/mortality
• Precancerous Conditions/pathology
• Precancerous Conditions/surgery
• Prognosis
• Sensitivity and Specificity
• Tomography, X-Ray Computed

The current standard treatment, at least in Europe, for patients with primarily resectable tumors, consists of surgery followed by adjuvant chemotherapy. But even in this prognostic favourable group, long term survival is disappointing because of high local and distant failure rates. Postoperative chemoradiation has shown improved local control and overalls survival compared to surgery alone but the value of additional radiation has been questioned in case of adjuvant chemotherapy. However, there remains a strong rationale for the addition of radiation therapy considering the high rates of microscopically incomplete resections after surgery. As postoperative administration of radiation therapy has some general disadvantages, neoadjuvant and intraoperative approaches theoretically offer benefits in terms of dose escalation, reduction of toxicity and patients comfort especially if hypofractionated regimens with highly conformal techniques like intensity-modulated radiation therapy are considered.

The NEOPANC trial is a prospective, one armed, single center phase I/II study investigating a combination of neoadjuvant short course intensity-modulated radiation therapy (5 × 5 Gy) in combination with surgery and intraoperative radiation therapy (15 Gy), followed by adjuvant chemotherapy according to the german treatment guidelines, in patients with primarily resectable pancreatic cancer. The aim of accrual is 46 patients.

The primary objectives of the NEOPANC trial are to evaluate the general feasibility of this approach and the local recurrence rate after one year. Secondary endpoints are progression-free survival, overall survival, acute and late toxicity, postoperative morbidity and mortality and quality of life.

NCT01372735.

• Clinical Trials, Phase I as Topic/methods
• Clinical Trials, Phase II as Topic/methods
• Humans
• Intraoperative Care/methods
• Neoadjuvant Therapy
• Prospective Studies
• Radiotherapy Dosage
• Radiotherapy, Adjuvant/methods
• Radiotherapy, Intensity-Modulated/methods
• Retroperitoneal Neoplasms/radiotherapy
• Retroperitoneal Neoplasms/surgery
• Sarcoma/radiotherapy
• Sarcoma/surgery

To evaluate efficacy and secondary resectability in patients with locally advanced pancreatic cancer (LAPC) treated with neoadjuvant chemoradiotherapy (CRT).

A total of 215 patients with locally advanced pancreatic cancer were treated with chemoradiation at a single institution. Radiotherapy was delivered with a median dose of 52.2 Gy in single fractions of 1.8 Gy. Chemotherapy was applied concomitantly as gemcitabine (GEM) at a dose of 300 mg/m² weekly, followed by adjuvant cycles of full-dose GEM (1000 mg/m²). After neoadjuvant CRT restaging was done to evaluate secondary resectability. Overall and disease-free survival were calculated and prognostic factors were estimated.

After CRT a total of 26% of all patients with primary unresectable LAPC were chosen to undergo secondary resection. Tumour free resection margins could be achieved in 39.2% (R0-resection), R1-resections were seen in 41.2%, residual macroscopic tumour in 11.8% (R2) and in 7.8% resection were classified as Rx. Patients with complete resection after CRT showed a significantly increased median overall survival (OS) with 22.1 compared to 11.9 months in non-resected patients. Median OS and disease-free survival (DFS) of all patients were 12.3 and 8.1 months respectively. In most cases the first site of disease progression was systemic with hepatic (52%) and peritoneal (36%) metastases.

A high percentage of patients with locally advanced pancreatic cancer can undergo secondary resection after gemcitabine-based chemoradiation and has a relative long-term prognosis after complete resection.

• adjuvant chemotherapy
• pancreatic cancer
• recurrence

• Chemotherapy with palliative intent
• Gemcitabine
• Pancreatic cancer
• Weekly high-dose 5-FU as a 24-hour infusion

Pancreatic cancer is still associated with a poor prognosis and remains—as the fourth leading cause of cancer related mortality—a therapeutic challenge. Overall long-term survival is about 1–5%, and in only 10–20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20–25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

Background. For M1 pancreatic adenocarcinomas pancreatic resection is usually not indicated. However, in highly selected patients synchronous metastasectomy may be appropriate together with pancreatic resection when operative morbidity is low. Materials and Methods. From January 1, 2004 to December, 2007 a total of 20 patients with pancreatic malignancies were retrospectively evaluated who underwent pancreatic surgery with synchronous resection of hepatic, adjacent organ, or peritoneal metastases for proven UICC stage IV periampullary cancer of the pancreas. Perioperative as well as clinicopathological parameters were evaluated. Results. There were 20 patients (9 men, 11 women; mean age 58 years) identified. The primary tumor was located in the pancreatic head (n = 9, 45%), in pancreatic tail (n = 9, 45%), and in the papilla Vateri (n = 2, 10%). Metastases were located in the liver (n = 14, 70%), peritoneum (n = 5, 25%), and omentum majus (n = 2, 10%). Lymphnode metastases were present in 16 patients (80%). All patients received resection of their tumors together with metastasectomy. Pylorus preserving duodenopancreatectomy was performed in 8 patients, distal pancreatectomy in 8, duodenopancreatectomy in 2, and total pancreatectomy in 2. Morbidity was 45% and there was no perioperative mortality. Median postoperative survival was 10.7 months (2.6–37.7 months) which was not significantly different from a matched-pair group of patients who underwent pancreatic resection for UICC adenocarcinoma of the pancreas (median survival 15.6 months; P = .1). Conclusion. Pancreatic resection for M1 periampullary cancer of the pancreas can be performed safely in well-selected patients. However, indication for surgery has to be made on an individual basis.