Ductal adenocarcinoma of the pancreatic head: A focus on current diagnostic and surgical concepts

Table 1 Summary of preoperative evaluation of pancreatic adenocarcinoma

Painless jaundice in an appropriately aged patient is highly suspicious for pancreatic cancer

Contrast-enhanced computer tomography is the diagnostic standard

High overall diagnostic sensitivity and specificity

Highly accurate in determining local respectability

Less adequate in identifying small hepatic metastases, extent of local lymphadenopathy and peritoneal tumor deposits

Magnetic resonance imaging gives additional information on small isodense or atypical pancreatic lesions

More accurate than contrast-enhanced computer tomography in detecting smaller hepatic metastases

Enhanced ultrasonography/fine-needle biopsy are reserved for the work-up of small lesions (< 2 cm), or in cases where a fine-needle biopsy is required before palliative or neoadjuvant therapy is initiated

Table 2 Indications for preoperative biliary drainage

Total bilirubin > 250 mmol/L

Acute cholangitis

Severe malnutrition and delayed surgery scheduled (relative indication)

Patients who require neo-adjuvant chemotherapy

Perioperative antibiotic treatment with penicillin in cases with evident infection of the biliary tree and in all patients undergoing biliary drainage

Table 3 Prevention of pancreatic fistula

There is currently no favored pancreatico-digestive anastomotic technique with regard to decreased pancreatic fistula rates

The routine use of octreotide can only be recommended in the case of:

Friable pancreatic tissue

Small diameter of the main pancreatic duct (< 3 mm)

Trans-anastomotic, percutaneously placed drainage of the main pancreatic duct decreases the risk of pancreatic fistula formation

Table 4 Improvement of radicality of resection

Resection	Exclusion of resection
Standard lymph node clearance for PPPD/CKW include the regional peripancreatic lymph nodes, hepato-duodenal ligament, common hepatic artery, portal vein, cranial portion of the superior mesenteric vein, right border along the mesenteric superior artery and celiac trunk	Extended lymphadenectomy can not be recommended
Vascular resection of the portal vein or superior mesenteric vein is feasible and safe and should not be an exclusion criterion in curative surgery	Thrombosis of the mesenteric-portal vein or tumoral infiltration > 180° of these vascular structures are contraindications in attempting curative resection

PPPD: Pylorus preserving pancreaticoduodenectomy; CKW: Classic Kausch-Whipple.