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To determine the prognostic influence of residual tumor at or within 1 mm of the mobilization margins (R1Mobilization) compared with transection margins (R1Transection) following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC).The prognostic strength of R1 status increases with frequency of margin positivity and is enhanced by protocol driven pathology reporting. Currently, margins are treated uniformly with tumor at or close to any margin considered of equal prognostic significance. The resection involves a mobilization phase freeing the posterior margin and anterior surface then a transection phase requiring lympho-vascular division forming the medial resection and pancreatic transection margin. The comparative assessment of the relative importance of tumor involvement of these different margins has not previously been investigated.Retrospective analysis of 148 consecutive resections for PDAC from 1996-2007 was performed. The individual (pancreatic transection, medial, posterior, and anterior surface) margins were separately identified and analyzed by a senior pathologist. An R1 resection was defined as microscopic evidence of tumoror = 1 mm from a resection margin. R1Mobilization tumor extension included both R1Anterior and R1Posterior cases; while R1Transection included pancreatic neck/body transection, R1Medial and adjacent transection margins.R1 status was confirmed in 109 patients (74%). The medial (46%) and posterior (44%) margins were most commonly involved. R1 status was found to an independent predictor of poor outcome (P0.001). R1Mobilization involvement only (n = 48) was associated with a significantly longer median survival of 18.9 months (95% CI, 13.7-24.8) versus 11.1 months (95% CI, 7.1-15.0) for those with R1Transection tumor involvement (n = 61) (P0.001). There was no significant difference in the survival of the R1Mobilization compared with R0 group (P = 0.52).Following pancreaticoduodenectomy for PDAC, involvement of the transection margins in contrast to mobilization margins defines a group whose outcome is significantly worse. This may impact upon the allocation of adjuvant therapy within the setting of randomized controlled trials.

Over a 21 year period, 245 cases of cancer of the pancreas were operated upon and followed-up at UCLA Hospital. A further 34 cases of periampullary tumor were treated by partial or total pancreatectomy. Apparent clearance of tumors at the time of pancreaticoduodenectomy that was confirmed by subsequent histopathology resulted in a patient survival time of 20.3 months as compared with a figure of 12.9 months when the pathological examination revealed tumor in a resection margin, although the surgeon believed that excision had been complete at the time of operation. Frozen section examination of resection margins is therefore mandatory. The result of performing a pancreaticoduodenectomy in which tumor was seen to be left behind was a survival time of only 6.8 months, which is similar to the survival time of 6.2 months following a palliative biliary bypass. Pancreaticoduodenectomy in patients over the age of 70 resulted in an average survival of only 7.6 months. Of patients having a palliative biliary bypass alone, 13% required subsequent reoperation to bypass distressing duodenal obstruction. A duodenal bypass should therefore be a routine concomitant of a biliary bypass. Total pancreatectomy with duodenectomy for pancreatic cancer gave an increased average survival of 26 months, and it is likely that the frequency of performance of this operation will increase.

In 128 patients with severe chronic pancreatitis and inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the pancreatic head was performed. Median post-operative hospitalization was 15.5 days, and the frequency of reoperation was 5.5%. One patient died during the early post-operative phase, and hospital mortality amounted to 0.8%. After a median follow-up period of 3.6 years (range of 7 months to 16 years), six of 127 patients died (late mortality of 4.7%). Seventy-seven per cent of the patients were completely free of abdominal pain, 67% returned to their former occupations. During the late follow-up period, the glucose metabolism was unchanged in 80.7% of the patients, in 13.7% it deteriorated, and in 5.5% it improved permanently; 80% of the patients experienced a marked increase in weight averaging 8.7 kg. Compared with the Whipple procedure, the duodenum-preserving resection of the head of the pancreas spares the patient with chronic pancreatitis a gastrectomy, duodenectomy, and resection of the extrahepatic biliary ducts. In terms of a subtotal resection, the limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the low early and late postoperative morbidity and mortality.