[Indications for the surgical management of pancreatic neoplasms]

[Minimally Invasive Resection of Cystic Pancreatic Neoplasia]

Zystische Pankreasneoplasien haben aufgrund ihrer hohen Prävalenz einen relevanten Stellenwert im klinischen Alltag eingenommen. Nur ein kleiner Teil der diagnostizierten Pankreaszysten erfordert eine chirurgische Therapie. Ist eine Resektion indiziert, so hängt die Wahl des passenden Operationsverfahrens von der Art, dem Ausmaß und der Lage der zystischen Pankreasneoplasie ab.

Zystische Pankreasneoplasien: Fall 1: Seitengang-IPMN im Pankreaskopf; Fall 2: muzinös-zystische Neoplasie (MCN) im Pankreasschwanz; Fall 3: solide pseudopapilläre Neoplasie (SPN) im Pankreasschwanz; Fall 4: Mixed-Type-IPMN im Pankreaskorpus.

Minimalinvasive Resektionstechniken bei zystischen Pankreasneoplasien: Fall 1: roboterassistierte Enukleation; Fall 2: laparoskopische Pankreaslinksresektion; Fall 3: roboterassistierte milzerhaltende Pankreasschwanzresektion; Fall 4: roboterassistierte Pankreassegmentresektion.

Die Heterogenität zystischer Pankreasneoplasien erfordert eine individualisierte Wahl des Operationsverfahrens, das bevorzugt minimalinvasiv und organerhaltend durchgeführt werden sollte.

[Pancreatic cystic space-occupying lesions-Diagnostics, treatment and follow-up care : Current recommendations taking the current German S3 guidelines on pancreatic cancer into account]

Due to their increased detection pancreatic cystic space-occupying lesions are becoming increasingly relevant in the clinical routine and represent a morphologically and biologically heterogeneous and thus clinically demanding as well as potentially (pre)malignant entity. As a result, recommendations for the diagnostics and treatment of pancreatic cystic tumors have now been incorporated into the current German S3 guidelines on pancreatic cancer. The diagnostics of pancreatic cystic space-occupying lesions are based on the following three elements: collection of relevant clinical information, performance of high-resolution imaging procedures and if diagnostic uncertainty persists, puncture diagnostics. Differentiated diagnostics are of essential importance as these represent the basis for an adequate treatment decision. Pancreatic cystic lesions with a relevant risk of malignant transformation, e.g., main duct intraductal papillary mucinous neoplasms (IPMN), followed by mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and generally pancreatic cystic lesions with risk factors independent of the entity, should be resected, whereas a differentiated and individualized approach is necessary, especially for branch-duct IPMNs. The serous cystic neoplasms (SCN) have no malignant potential and do not require any treatment if they are asymptomatic. Important principles in surgery of pancreatic cancer, such as adequate surgical resection taking oncological standards into account and standardized appropriate histopathological processing of the specimens as well as intraoperative frozen section analysis also play an important role in pancreatic cystic space-occupying lesions. An annual follow-up seems to be meaningful, especially for IPMNs.

[Surgical treatment of pancreatic cancer-What is new?]

The incidence of pancreatic ductal adenocarcinoma is continuously increasing and will become the second leading cause of cancer-related death in Europe and the USA by 2030. With a 5-year overall survival rate of less than 10% the prognosis remains poor. So far surgical tumor resection remains the only curative treatment option, which is now partially supported by multimodal neoadjuvant and adjuvant therapy concepts. Due to the aggressive tumor biology patients with advanced pancreatic cancer in particular can profit from these multimodal therapy concepts. Additionally, in recent years surgical treatment was optimized, the criteria for tumor resectablity were defined and minimally invasive surgery was widely introduced. This review article summarizes the newest developments and the new German S3 guidelines concerning surgery of pancreatic cancer.

[Better Therapy for Pancreatic Cancer through More Radical Surgery?]

Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.Even if even more radical surgical approaches such as an "extended" lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an "existing limited prognosis". On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.