Especially Dangerous and Therefore Anxious Operations:  Comment on “Pancreatic Endocrine Tumors With Major Vascular Abutment, Involvement, or Encasement and Indication for Resection”

In the summer of 1904, Sir Frederick Treves, the most famous surgeon of his time, wrote to King Edward seeking approval of the decision to retire from surgical practice. “I am anxious to retire from active practice,” Treves wrote, “and I trust Your Royal Highness will approve of my doing so. I have had 25 years of incessant and exacting work, and of late years I have been almost exclusively concerned with specially dangerous–and therefore anxious–operations.”¹ Norton and his colleagues at the National Institutes of Health and Stanford University hospitals report their quarter of a century of incessant and exacting work with the dangerous and anxious operative treatment of PETs with major vascular involvement. The operations are dangerous because these tumors may be large and associated with pancreatic and peripancreatic fibrosis. Despite well-formulated and safe surgical techniques of vascular resection and reconstruction, these operations carry extra physical and emotional work, and the postoperative morbidity is worse than that of operations without vascular involvement. Anxious debate rattles the surgeon because the clinical course of PETs is capricious. Many advanced tumors pursue an indolent course, and long-term survival with advanced disease is possible. Other ostensibly early and small tumors seem to spread quickly and widely to the liver. The pancreatic surgeon worries whether the risk of resecting advanced PETs outweighs the benefits. The experience of Norton et al indicates that surgical resection of PETs with major vascular involvement and nodal or distal metastatic spread is safe and may be effective. Although carrying the imperfections of a retrospective cohort study at bicoastal centers during several decades, the ineluctable conclusion from this experience is that surgical resection of PETs with vascular involvement is analogous to that of adenocarcinoma of the pancreas, and involvement of the splanchnic vasculature is not a contraindication to operation. This hard-earned experience is encouraging because their findings suggest that patients with concomitant liver metastatic disease may also benefit from operative resection. Treves retired from the practice of surgery at age 50. The advice by Norton et al to refer patients with advanced PETs to multidisciplinary centers is good advice, and one hopes that it will keep them and their kind working on this problem in the operating room for decades to come.