0
Invited Critique |

Pancreatoduodenectomy for Pancreatic Adenocarcinoma—Invited Critique

Michael Trede, MD, HONFRCS, HONFACS
Arch Surg. 2002;137(7):773. doi:10.1001/archsurg.137.7.773.
Text Size: A A A
Published online

Extract

The ultimate panegyric that one of my surgical teachers in London would stoop to (if he were really satisfied with something I had done) would be to murmur, "I couldn't have done it better myself!" And that was (with tongue in cheek) my immediate reaction, when reading this editorial. I agree with everything, and I have little to add.

Of the 4 problems that bedevil the treatment of pancreatic carcinoma screening (or at least early diagnosis), accurate staging, postoperative mortality and long-term survival-only staging, and mortality have been brought closer to a solution. But that has not so far altered my considered opinion that "ductal adenocarcinoma of the pancreas is an incurable disease."1 Incurable, that is, by the means at our disposal in this year 2002. It is true that the actual (not actuarial) 5-year survival of 118 patients who had their ductal adenocarcinoma of the head of the pancreas removed by an R0 resection at our clinic more than 5 years previously amounts to 31% (ie, 37 patients).1 But that does not mean that they were cured. Twenty of these 37 have died subsequently so far. The rest will follow. Even more poignant are the statistics concerning those 9 patients who were able to undergo surgery for a truly early adenocarcinoma of the pancreas (pT1a, N0, M0, according to the 1997 Union Internationale Contre le Cancer [UICC] TNM classification). Seven have crossed the 5-year survival line. The remaining 2 will also reach it, but 6 have succumbed to a recurrence as late as 116, 137, or even 142 months after that resection.1 And it is worth remembering here that there are many patients on record who apparently survived the histologically verified diagnosis of pancreatic cancer for as long as 14 years without resection or any definitive treatment at all.2 Of course, as surgeons, we are in the hands of our pathologists, and "even if you like and admire your pathologist as I do mine, you cannot give him your full trust when it comes to pancreatic biopsies."3 We can never be absolutely sure that every one of these 118 pancreatoduodenectomies was an R0 procedure, or that each of those 9 really were early cancers. Actually, subsequent events seem to show that this was not so. From all this, we have to conclude that surgery alone cannot cure pancreatic carcinoma. But this is not to say that it cannot at least provide good-quality palliation at a reasonably low risk and for a worthwhile period. Pancreatoduodenectomy for cancer is in this context much like democracy is in politics, of which Churchill once said, "it leaves much to be desired, but it is the best we have."

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

First Page Preview

View Large
/>
First page PDF preview

Figures

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 2

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles
Jobs
brightcove.createExperiences();