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Invited Critique
July 2002

Pancreatoduodenectomy for Pancreatic Adenocarcinoma—Invited Critique

Author Affiliations

Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2002

Arch Surg. 2002;137(7):773. doi:10.1001/archsurg.137.7.773

The ultimate panegyric that one of my surgical teachers in London would stoop to (if he were really satisfied with something I had done) would be to murmur, "I couldn't have done it better myself!" And that was (with tongue in cheek) my immediate reaction, when reading this editorial. I agree with everything, and I have little to add.

Of the 4 problems that bedevil the treatment of pancreatic carcinoma screening (or at least early diagnosis), accurate staging, postoperative mortality and long-term survival-only staging, and mortality have been brought closer to a solution. But that has not so far altered my considered opinion that "ductal adenocarcinoma of the pancreas is an incurable disease."1 Incurable, that is, by the means at our disposal in this year 2002. It is true that the actual (not actuarial) 5-year survival of 118 patients who had their ductal adenocarcinoma of the head of the pancreas removed by an R0 resection at our clinic more than 5 years previously amounts to 31% (ie, 37 patients).1 But that does not mean that they were cured. Twenty of these 37 have died subsequently so far. The rest will follow. Even more poignant are the statistics concerning those 9 patients who were able to undergo surgery for a truly early adenocarcinoma of the pancreas (pT1a, N0, M0, according to the 1997 Union Internationale Contre le Cancer [UICC] TNM classification). Seven have crossed the 5-year survival line. The remaining 2 will also reach it, but 6 have succumbed to a recurrence as late as 116, 137, or even 142 months after that resection.1 And it is worth remembering here that there are many patients on record who apparently survived the histologically verified diagnosis of pancreatic cancer for as long as 14 years without resection or any definitive treatment at all.2 Of course, as surgeons, we are in the hands of our pathologists, and "even if you like and admire your pathologist as I do mine, you cannot give him your full trust when it comes to pancreatic biopsies."3 We can never be absolutely sure that every one of these 118 pancreatoduodenectomies was an R0 procedure, or that each of those 9 really were early cancers. Actually, subsequent events seem to show that this was not so. From all this, we have to conclude that surgery alone cannot cure pancreatic carcinoma. But this is not to say that it cannot at least provide good-quality palliation at a reasonably low risk and for a worthwhile period. Pancreatoduodenectomy for cancer is in this context much like democracy is in politics, of which Churchill once said, "it leaves much to be desired, but it is the best we have."