THE MAYO CLINIC APPROACH TO THE SURGICAL TREATMENT OF ADENOCARCINOMA OF THE PANCREAS

Abstract

In the preceding articles of this issue of The Surgical Clinics of North America, a coterie of experts have addressed the state of the art and future directions in the epidemiology, diagnosis, and surgical and oncologic treatment of ductal carcinoma of the pancreas. This article presents the authors' current approach to the management of patients harboring this particularly virulent neoplasm, with emphasis on clinical and surgical considerations. The authors recognize that management remains in a state of evolution, that their approach in the future may well be modified, and that experts in the field may espouse approaches that differ. For those areas of diagnosis and therapy that are controversial, the authors endeavor to provide support and the rationale for their biases. Comments are limited to ductal carcinoma of the pancreas because of the differences in the natural history and management of nonductal pancreatic and periampullary tumors of the pancreas.

In the 60 years since Whipple's first one-stage pancreatoduodenectomy, enthusiasm for the surgical procedure has fluctuated. The complexity of the procedure, high rates of morbidity and mortality, and poor long-term outcome led colleagues at the Mayo Clinic to question whether radical pancreatoduodenectomy should be abandoned.⁴⁶ In the nearly 20 years since that report, improved diagnostic techniques that allow more appropriate selection of candidates for potentially curative resection, refinements in surgical technique, anesthesia support, and postoperative care have improved the overall safety of the procedure and rekindled the authors' enthusiasm; therefore, these patients are approached aggressively. Moreover, some reports have suggested that survival after resection of ductal carcinoma of the pancreatic head has increased.44, 51Although reviews of the authors' experience failed to confirm improvement in long-term survival,²⁹ the authors recognize that resection is recognized as the only likelihood for cure, and surgery continues to be recommended for those patients with resectable tumors who are deemed fit candidates for surgery. The authors' enthusiasm is based on the fact that the surgical procedure now can be performed more safely, the Whipple procedure has achieved a secure role in the management of selected benign disorders of the head of the pancreas and periampullary region, and the patient's quality of life after resection depends more on recurrence of malignant disease than on physiologic alterations inherent to the resection and reconstruction.25, 47

The management principles that the authors espouse in patients with ductal carcinoma of the pancreas are to assess these patients with the most efficient and least invasive diagnostic approach possible, that resection offers the only potential for cure, and that in fit candidates with clinically resectable lesions in the head of the pancreas, the best palliation is provided surgically.