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INTRODUCTION

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Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer-related deaths in the United States and the eighth worldwide. Despite advances in medical therapy, survival remains poor. The median survival for patients diagnosed with PDA is 4 to 6 months. However, for the 10% to 20% of patients who are operative candidates at the time of diagnosis, the 5-year overall survival approaches 25%, and the median survival is in the range of 20 to 22 months. The incidence of pancreatic cancer has slowly risen over the last decade, resulting in over 310,000 annual deaths worldwide.1 The aggressive nature of pancreatic cancer can be seen as each year the incidence nearly matches the death rate, and accounts for about 42,000 deaths annually in the United States alone.2 Given this aggressiveness and poor long-term outcomes, high variability exists in the surgical approach to patients with pancreatic cancer. Many aspects of surgery for pancreatic cancer have been evaluated including the appropriate workup and staging, need for laparoscopy, need for extended lymphadenectomies, and the use of vascular reconstruction to improve morbidity and survival. The following is a comprehensive review of the available data regarding the surgical management of patients with resectable pancreatic cancer.

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CLINICAL PRESENTATION

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Pancreatic cancer often presents late in its disease course with various nonspecific symptoms making early diagnosis difficult. Many patients do not typically present with symptoms until their disease has progressed, often past the point where surgical therapy can offer a cure. Patients with tumors located in the body and tail usually present after the tumor grows sufficiently large to cause invasion of contiguous structures and/or metastatic disease. Most patients with PDA present with lesions in the pancreatic head or neck (65%), with 15% present in the body/tail, and the remaining 20% being diffuse in nature. The classically described “Courvoisier's sign” is present only in 30% of people at the time of diagnosis. Patients often present with symptoms including abdominal pain (70%), fatigue (60%), malaise (60%), and painless jaundice (50%). Other presenting symptoms may include clay-colored stool, dark urine, pruritus, weight loss, and anorexia. New-onset diabetes can be a sign of pancreatic cancer, with up to 30% of newly diagnosed patients receiving a diagnosis of diabetes within the preceding 2 years.3,4

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PANCREATIC ADENOCARCINOMA STAGING

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The staging of tumors of the pancreas continues to evolve and most recently follows the American Joint Committee on Cancer (AJCC), seventh edition, TNM staging system5 (Table 141-1). In the current version it should be noted that T3 tumors are those extending beyond the pancreas and not involving the superior mesenteric artery (SMA) or celiac axis. T3 disease no longer precludes patients from resection as venous reconstruction in these patients has survival rates similar to those without venous invasion. In addition, regional lymph node disease is categorized as being present or absent, without designation based ...

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