Editorial
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 7, 2017; 23(21): 3765-3770
Published online Jun 7, 2017. doi: 10.3748/wjg.v23.i21.3765
Role of surgery in pancreatic cancer
Trond A Buanes
Trond A Buanes, Department of Hepato-Pancreatico-Biliary Surgery, Oslo University Hospital, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Pb 4956 N-0424 Oslo, Norway
Author contributions: Buanes TA solely contributed to the manuscript.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Trond A Buanes, MD, PhD, Professor, Department of Hepato-Pancreatico-Biliary Surgery, Oslo University Hospital, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Nydalen, Pb 4956 N-0424 Oslo, Norway. trond.buanes@medisin.uio.no
Telephone: +47-23-070958 Fax: +47-23-072526
Received: January 26, 2017
Peer-review started: February 2, 2017
First decision: March 3, 2017
Revised: March 17, 2017
Accepted: April 21, 2017
Article in press: April 21, 2017
Published online: June 7, 2017
Abstract

Treatment of pancreatic cancer is multimodal and surgery is an essential part, mandatory for curative potential. Also chemotherapy is essential, and serious postoperative complications or rapid disease progression may preclude completion of multimodal treatment. The sequence of treatment interventions has therefore become an important concern, and numerous ongoing randomized controlled trials compare clinical outcome after upfront surgery and neoadjuvant treatment with subsequent resection. In previous years, borderline resectable and locally advanced pancreatic cancer was most often considered unresectable. More effective chemotherapy together with the latest improvements in surgical expertise has resulted in extended operations, pushing the borders of resectability. Multivisceral resections with or without resection of major mesenteric vessels are now performed in numerous patients, resulting in better outcome, recorded as overall survival and/or patient reported outcome. But postoperative morbidity increases concurrently, and clinical benefit must be carefully evaluated against risk of potential harm, associated with new comprehensive multimodal treatment sequences. Even though cost/utility analyses are deficient, extended surgery has resulted in significantly longer and better life for many patients with no other treatment alternative. Improved selection of patients to surgery and/or chemotherapy will in the near future be possible, based on better tumor biology insight. Clinically available biomarkers enabling personalized treatment are forthcoming, but these options are still limited. The importance of surgical resection for each patient’s prognosis is presently increasing, justifying sustained expansion of the surgical treatment modality.

Keywords: Adjuvant chemotherapy, Neoadjuvant chemotherapy, Metastasis, Pancreatic cancer, Patient reported outcome, Survival

Core tip: Both surgery and chemotherapy are mandatory in multimodal treatment of pancreatic cancer to obtain curative potential. The sequence of interventions is a core question: Upfront surgery or neoadjuvant chemotherapy with subsequent resection. Also the role of extended operations incorporating reconstruction of major mesenteric vessels and multivisceral resections is a matter of ongoing evaluation. The current direction of this development is increasing prognostic importance of surgical resection.