Surgery for pancreatic cancer

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6945.1715 (Published 25 June 1994) Cite this as: BMJ 1994;308:1715
  1. R M Charnley,
  2. R C Spiller,
  3. J Doran
  1. Departments of Surgery and Gastroenterology, University Hospital, Nottingham NG7 2UH.

    EDITOR, - It has been common practice, particularly in Britain, for patients with cancer of the pancreatic head and for some patients with periampullary cancer (which carries a much better prognosis) to be denied surgical assessment. Paul Ellis and David Cunningham rightly state that “patients with pancreatic cancer should not be denied the surgical option, and assessment by an experienced pancreatic surgeon is essential to achieve the best outcome.”1 We wish to explain why, in the 1990s, surgical assessment is so important in patients with pancreatic tumours.

    In the 1960s partial duodenopancreatectomy (Whipple's operation) was associated with a mortality of 30%. This led Crile and others to recommend that, for a disease that in the best hands gave a five year survival of 10%, patients should receive only palliative treatment.2 Since then mortality has dropped dramatically owing to better anaesthetic and surgical techniques. Cameron et al recently reported a 0% mortality after 145 consecutive Whipple's operations.3 Others have reported mortality below 5%.4 Selection of patients has also improved, particularly with regard to the identification of metastases, size of tumour, type of tumour (periampullary or ductal), and invasion of major blood vessels. This has been possible because of better imaging techniques, including ultrasonography, computed tomography, and endoscopic retrograde pancreatography.

    A tumour of the pancreas is not necessarily a ductal adenocarcinoma. De Jong et al found that, of 353 non-functioning tumours of the pancreas 31 were non-ductal tumours.5 These tumours have a much better prognosis than ductal carcinomas, with a five year survival in the region of 50% after curative resection. Periampullary tumours also have a much better prognosis than ductal carcinomas and make up about a tenth of all proximal pancreatic cancers.

    It is vital that these patients are assessed properly for surgery, otherwise patients with curable tumours will be assigned inappropriate palliative treatment.


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