Surgical techniques for improving outcomes in pancreatic ductal adenocarcinoma

Abstract

Pancreatic ductal adenocarcinoma is a devastating disease with extremely poor survival despite patients undergoing potentially curative resections and improvements in chemotherapeutic agents. Surgery for operable cancer in the head of the pancreas typically involves an open pancreaticoduodenectomy with a post-operative median survival of 21 months. Newer surgical techniques, however, aim to improve patient outcomes in terms of both their hospital experience and better oncological results. This article focuses on the evidence to date for some of these surgical techniques including laparoscopic and robotic surgery, the no-touch technique, venous and arterial resection, intra-operative radiofrequency ablation and intra-operative irreversible electroporation. With the increased use of these techniques we hope to see better quality of life and survival for these patients.

Keywords::

• irreversible electroporation therapy
• laparoscopic surgery
• no-touch technique
• pancreatic cancer
• pancreaticoduodenectomy
• radiofrequency ablation
• robotic surgery
• venous and arterial resection

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Pancreatic ductal adenocarcinoma has a dismal prognosis.

• Despite potentially curative resection and anticancer therapies, survival rates are still poor.

• Laparoscopic and robotic pancreaticoduodenectomy results in better post-operative recovery, without compromising oncological outcome.

• There have been limited trials involving the no-touch surgical technique, but this may lead to better disease-free and overall survival.

• Pancreaticoduodenectomy with venous resection is increasingly used without worsening perioperative morbidity or mortality.

• Venous resection enables patients previously thought to have unresectable disease, or those who would have positive medial resection margins, to undergo R0 resection.

• Some novel surgical techniques for pancreatic ductal adenocarcinoma are being tried and developed resulting in more patients deemed suitable for surgery and may lead to better outcomes.

• With all the above-mentioned techniques, there is a paucity of level I and II evidence; therefore, the conclusions are not robust.