Update on Management Periampullary/Pancreatic Head Cancer

Abstract

Management of pancreatic head (ductal adenocarcinoma) and periampullary cancer is difficult owing to its insidious onset and hence late diagnosis, lack of significant diagnostic, predictive and prognostic biomarkers, and the inherent tumor biology of being relatively resistant to chemotherapy and radiotherapy. Surgery of this deep-seated gland is technically challenging and the procedure is called pancreaticoduodenectomy (PD). It involves removal of pancreatic head, duodenum, bile duct and gallbladder ± distal stomach. The reconstruction involves pancreatoenteric anastomosis (pancreaticojejunostomy or pancreaticogastrostomy), hepaticojejunostomy, and gastro/duodenojejunostomy. At times, vascular resection and adjacent organ resection are required for complete extirpation (R0) of the cancer. Over the years, surgical procedures used in the management of pancreatic cancer (PC) have been refined and with better anesthesia and perioperative and postoperative care, the operative mortality has dropped to < 5% but morbidity still remains close to 40%. The most common cause of severe morbidity is occurrence of postoperative pancreatic fistula. Post pancreatectomy hemorrhage and delayed gastric emptying are the other two major morbidities extending hospital stay and are at times life-threatening. New classification systems, better imaging, and new chemotherapeutic/targeted drug combinations for neoadjuvant/adjuvant treatment with/without refined radiotherapy techniques and centralization of treatment have helped in selecting the best patients for aggressive treatment with the aim of improving abysmally low overall survival. The present review highlights recent updates in the management of PC.