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The last 40 years have seen remarkable advances in what we know about pancreatic neoplasms, their biology, how we approach their management, and the quality and safety of surgical treatment. Some can be attributed to better surgical technique, but most are due to developments in imaging, along with nonsurgical interventions such as endoscopic retrograde cholangiopancreatography (ERCP), stenting, and percutaneous or endoscopic needle biopsies. In most cases the diagnosis can be made preoperatively; the extent of the tumor can be determined; and the timing as well as the nature of the probable surgical procedure can all be planned before or even instead of a laparotomy. Pancreaticoduodenectomy has become sufficiently safe (2–5% mortality, median postoperative length of stay 8 days in high-volume centers) that the operation can be offered to most patients without biopsy proof of malignancy because the risk of missing a cancer now exceeds the risk of mistakenly operating for a benign condition. This radical approach to resection applies as well to ampullary neoplasms, which contain cancer in up to 50% of villous adenomas in spite negative biopsies. The conclusion is that a negative biopsy should not deter resection of a lesion with significant malignant potential.

Yet there are still important shortcomings to the methods we have. There is no reliable screening test for pancreatic cancer and, even if one were invented that had a remarkable 99% accuracy, we would probably be unable to find the lesion at the desired very early stage of growth because current imaging with the best computed tomography (CT) or endoscopic ultrasound (EUS) still cannot “see” masses much smaller than 1 cm (at which size many pancreatic adenocarcinomas have already spread).

For purposes of staging pancreatic cancers, multidetector contrast-enhanced angio-CT is as good as we have for evaluating the mesenteric, celiac, and hepatic blood vessels, but it still misses small liver or peritoneal metastases in at least 10% of cases of apparently resectable cancers.1 In addition, the use of preoperative laparoscopy will in another 10% demonstrate peritoneal dissemination of cancer cells that indicate a significantly diminished prognosis.2

There is a consensus that preoperative biliary stenting is unnecessary if the operation can be expeditiously performed, but it is useful when the patient is uncomfortable with pruritus and relief by biliary decompression will not be immediate or when neoadjuvant treatment is planned. The fear of increased postoperative surgical site infections has not been substantiated in a recent randomized controlled trial.3 Whether neoadjuvant therapy confers a benefit is debatable, either for downstaging borderline resectable cancers involving the mesenteric vessels or for increasing long-term survival.4 The M.D. Anderson group has argued that neoadjuvant chemoradiation helps to define the 25% of patients in whom metastases are predestined to blossom immediately, ensures delivery of the treatment to some patients who would not tolerate or receive postoperative adjuvant treatment, and may improve survival, perhaps by reducing positive resection margins. However, with the relatively ineffective chemotherapy drugs ...

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