Surgical treatment of pancreatic cancer

The only way to cure the patient with adenocarcinoma of the pancreas (RT) is surgical excision of the tumor. The standard surgical treatment of resectable pancreatic carcinoma is considered the classic pancreatoduodenectomy (PD) with the Kausch-Whipple procedure, or the pylorus-preserving PD with the Traverso-Longmire method. The most difficult technically and at the same time the most important PD stage from an oncological point of view is the separation of the head of the pancreas from the superior mesenteric artery. Over the last decades several PD modifications have been developed, focusing on this maneuver in the early phase of the operation, i.e. before the pancreas is cut (an irreversible stage of the procedure). These procedures in the English literature are called “artery-first approach” or “SMA-first approach”. The term “mesopancreas” was created. Complete removal of the mesopancreas together with the proximal part of the jejunum is considered an R0 resection in the case of a tumor of the head of the pancreas with direct or indirect vascular invasion, or metastases to regional lymph nodes, and in English literature it is referred to as pancreatoduodenectomy with systematic mesopancreas dissection (SMDPD). Distal resection of the pancreas (DRT) due to cancer, is associated with a high percentage of positive margins, insufficient number of removed lymph nodes, low survival rates. A new technique was developed - a radical proximal-distal modular pancreatosplenectomy (RAMPS). In RAMPS, surgical operations proceed from the side of the pancreas head towards the tail, the pancreas is cut early, and the splenectomy is performed at the final stages of the procedure. Currently, following the PD model, attempts are made to further modify the original RAMPS technique, especially in the direction of SMA-first approach. In patients with borderline resectable pancreatic tumors or locally advanced tumors, after neoadjuvant treatment, a technique of radical resection with preservance of arterial vessels - “the TRIANGLE operation” has been elaborated. Despite the tremendous progress of surgical techniques, RT is still detected too late in the phase preventing effective resection.