Pancreatic cancer is a common cause of cancer death in the developed world. Currently, resection is the only chance of long-term survival. The post-operative mortality in nonspecialist centres often exceeds 20% but is around 6% or less in specialist centres. The overall complication rate even in specialist centres is 18–54%. An analysis of eleven large series of pancreatic resections shows an incidence of common complications of 10.4% for fistula, 9.9% for delayed gastric emptying, 4.8% for bleeding, 4.8% for wound infection and 3.8% for intra-abdominal abscess. The median hospital stay is 13–18 days in different series. The re-operation rate varies from 4 to 9% with a mortality rate of 23 to 67%. Major complications are a significant factor in post-operative mortality, especially if they require re-operation. The use of octreotide or somatostatin to prevent complications is supported by several multicentre, double-blind, randomized controlled trials. The best way to improve outcome is to concentrate pancreatic cancer care in regional specialist centres.

1.
Parker SL, Tong T, Bolden S, Wingo PA: Cancer statistics. CA Cancer J Clin 1997;47:5–27.
2.
Gudjonsson B: Cancer of the pancreas. Fifty years of surgery. Cancer 1987;60:2284–2303.
3.
Hermanenk P, Gall FP, Wittlund CH: Pancreatic ductal adenocarcinoma surgery. Int J Pancreatol 1994;16:302–304.
4.
Pour PM, Egams H, Takiyama Y: Patterns of growth and metastases of induced pancreatic cancer in relation to prognosis and its clinical implications. Gastroenterolgy 1991;100:529.
5.
Cubilla AG, Fortner J, Fitzgerald PJ: Lymph node involvement in carcinoma head of pancreas. Cancer 1978;41:880–887.
6.
Edge SB, Schmeigher JR, Rosenlif LF, Willheim MC: Pancreatic cancer resectional outcomes in American university centers 1988–1990. Cancer 1993;71:3502–3508.
7.
Conlon KC, Klimstra DS, Brennan MF: Long-term survival after curative resection for pancreatic ductal adenocarcinoma: Clinical-pathological analysis of 5-year survivors. Ann Surg 1996;223:237–239.
8.
Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, Pitt HA, Lillemoe KD: Pancreatoduodenectomy with or without extended retroperitoneal lymphadectomy for periampullary adenocarcinoma: Comparison of morbidity and mortality and short-term exposure. Ann Surg 1999;229:613–622.
9.
Bottger T, Junginger T: Factors influencing morbidity and mortality after pancreaticoduodenectomy: Critical analysis of 221 resections. World J Surg 1999;23:164–172.
10.
Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J: One hundred and forty-five consecutive pancreatoduodenectomies without mortality. Ann Surg 1993;217:430–435.
11.
Neoptolemos JP, Russell RC, Bramhall S, Theis B: Low mortality following resection for pancreatic and periampullary tumours in 1,026 patients: UK survey of specialist pancreatic units. UK pancreatic group. Br J Surg 1997;84:1370–1376.
12.
Russell RC: Surgical resection for cancer of the pancreas. Baillières Clin Gastroenterol 1990;4:889–916.
13.
Trede M, Schwall G, Saeger HD: Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg 1990;211:447–458.
14.
Trede M, Saeger HD, Schwall G, Rumstadt B: Resection of pancreatic cancer. Surgical achievements. Langenbecks Arch Surg 1998;383:121–128.
15.
Tsuchida R, Tsunoda T, Ishida T, Saitoh Y: Resection for pancreatic cancer: The Japanese experience. Baillières Clin Gastroenterol 1990;4:931–939.
16.
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA: Six hundred and fifty consecutive pancreaticoduodenectomies in the 1990s. Ann Surg 1997;226:248–260.
17.
Gouma DJ, van Geenen RC, van Guilk TM, de Haan RJ, de Wit LT, Busch OR, Obertop H: Rates of complications and death after pancreatoduodenectomy: Risk factors and the impact of hospital volume. Ann Surg 2000;232:786–795.
18.
Bramhall SR, Neoptolemos JP: Adjuvant chemotherapy in pancreatic cancer. Int J Pancreatol 1997;21:59–63.
19.
Büchler M, Friess H, Schultheiss KH, Glebhardt C, Klubel R, Muhrer KH, Winklemann M, Wagener T, Klapdor R, Kaul M: A randomised controlled trial of adjuvant immunotherapy (murine monoclonal antibody 493/32) in resectable pancreatic cancer. Cancer 1991;68:1507–1512.
20.
Friess H, Büchler MC, Beglinger C, Weber A, Kunz J, Fritsch K, Dennler HJ, Beger HG: Low-dose octreotide treatment is not effective in patients with advanced pancreatic cancer. Pancreas 1993;8:540–545.
21.
Friess H, Büchler MC, Kruger M, Beger HG: Treatment of duct carcinoma of the pancreas with the LH-RH analogue Buserelin. Pancreas 1992;7:516–521.
22.
Neoptolemos JP, Dunn JA, Moffitt DD, Almond J, Link K, Beger H, Bassi C, Falconi M, Pederzoli P, Dervenis C, Fernandez-Cruz L, Lacaine F, Pap A, Spooner D, Kerr DJ, Friess H, Büchler M: Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: A randomised controlled trial. Lancet 2001;358:1576–1585.
23.
Northern and Yorkshire Cancer Registry and Information Service: Cancer treatment policies and their effect on survival – Pancreas. NYCRIS 2000;section 4.3:19.
24.
Crist DW, Sitzmann JV, Cameron JL: Improved hospital morbidity, mortality and survival after the Whipple procedure. Ann Surg 1987;206:358–365.
25.
Sener SF, Fremgen A, Menck HR, Winchester DP: Pancreatic cancer: A report of treatment and survival trends for 100,313 patients diagnosed from 1985 to 1995, using the National Cancer Database. J Am Coll Surg 1999;189:1–7.
26.
Howard JM: Pancreaticoduodenectomy: Forty-one consecutive Whipple resections without an operative mortality. Ann Surg 1968;168:629–640.
27.
Trede M: The surgical treatment of pancreatic carcinoma. Surgery 1985;97:28–35.
28.
Braasch JW, Rossi RL: Pyloric preservation with the Whipple procedure. Surg Clin North Am 1985;65:263–271.
29.
Grace PA, Pitt HA, Tompkins RK, Den Besten L, Longmire WP: Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 1986;151:141–149.
30.
Braasch JW, Deziel DJ, Rossi RL, Watkins E Jr, Winter PF: Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg 1986;204:411–418.
31.
Pelligrini CA, Heck CF, Raper S, Way LW: An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg 1989;124:778–781.
32.
Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Listrup D: Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992;127:945–950.
33.
Wade TP, Radford DM, Virgo KS, Johnson FE: Complications and outcome in the treatment of pancreatic adenocarcinoma in the United States veterans. J Am Coll Surg 1994;179:38–48.
34.
Friess H, Uhl W, Beger HG, Büchler MW: Surgical treatment of pancreatic cancer. Dig Surg 1994;11:378–386.
35.
Van Heerden JA: Pancreatic resection for carcinoma of the pancreas: Whipple versus total pancreatectomy – An institutional perspective. World J Surg 1984;8:880–888.
36.
Cunningham JD, Weyant MT, Levitt M, Brower ST, Aufses AH: Complications requiring reoperation following pancreatectomy. Int J Pancreatol 1998;24:23–29.
37.
Fernandez-del Castillo C, Rattner DW, Warshaw AL: Standards for pancreatic resection in the 1990s. Arch Surg 1995;130:295–300.
38.
Watanapa P, Williamson RCN: Resection of the pancreatic head with or without gastrectomy. World J Surg 1995;19:403–409.
39.
Reinders ME, Allema JH, van Guilk TM, Karsten TM, de Wit LT, Verbeek PCM, Rauws EJ, Gouma DJ: Outcome of microscopic nonradical, subtotal pancreatoduodenectomy (Whipple resection) for treatment of pancreatic head tumours. World J Surg 1995;19:410–415.
40.
Sperti C, Pasquali C, Piccoli A, Pedrazzoli S: Survival after resection for ductal adenocarcinoma of the pancreas. Br J Surg 1996;83:625–631.
41.
Talamini MA, Moesinger MD, Pitt HA, Sohn TA, Hruban RH, Lillemoe KD, Yeo CJ, Cameron JL: Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg 1997;225:590–600.
42.
Nitecki SS, Sarr MG, Colby TV, van Heerden JA: Long-term survival after resection for ductal adenocarcinoma of the pancreas. Ann Surg 1995;221:59–66.
43.
Gilsdorf RB, Spanos P: Factors influencing morbidity and mortality in pancreatoduodenectomy. Ann Surg 1973;177:332–337.
44.
Bakkevold KE, Kambestd B: Morbidity and mortality after radical and palliative pancreatic cancer surgery. Risk factors influencing the short-term results. Ann Surg 1993;217:356–368.
45.
Tsao JI, Rossi RL, Lowell JA: Pylorus preserving pancreatoduodenectomy. Is it an adequate cancer operation. Arch Surg 1994;129:405–412.
46.
Hannoun L, Riberio J, Norlinger B, Elriwini M, Tiret E, Parc R: A report of forty-four instances of pancreatoduodenal resection in patients more than seventy years of age. Surg Gynecol Obstet 1993;177:556–560.
47.
Geer RJ, Brennan MF: Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg 1993;165:68–73.
48.
Matsumoto Y, Fujii H, Miura K, Inoue S, Sekikawa T, Aoyama H, Ohnishi N, Sakai K, Suda K: Successful pancreatojejunual anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175:555–562.
49.
Büchler M, Friess H, Wagner M, Kulli C, Wagener V, Z’graggen K: Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883–889.
50.
Gouma DJ, Nieveen van Dijkum EJM, Obertop H: Pancreatic cancer: Matters for debate. The standard diagnostic work-up and surgical treatment of pancreatic head tumours. Eur J Surg Oncol 1999;25:113–123.
51.
Berberat PO, Friess H, Kleeff J, Uhl W, Büchler MW: Prevention and treatment of complications in pancreatic cancer surgery. Dig Surg 1999;16:327–336.
52.
Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA: Pancreatoduodenectomy for cancer of the head of the pancreas. Ann Surg 1995;221:721–733.
53.
Szentes MJ, Traverso LW, Kozarek RA, Freeny PC: Invasive treatment of pancreatic fluid collections with surgical and nonsurgical methods. Am J Surg 1991;161:600–605.
54.
Freeny PC: Percutaneous management of pancreatic fluid collections. Baillières Clin Gastroenterol 1992;6:259–272.
55.
Oglevie SB, Casola G, van Sonnenberg E, D’Agostino HB, Olaoide R, Fundell L: Percutaneous abscess drainage: Current applications for critically ill patients. J Int Care Med 1994;9:191–206.
56.
Van Sonnenberg E, Wittich GR, Goodacre BW, Casola G, D’Agostino HB: Percutaneous abscess drainage: Update. World J Surg 2001;25:362–369.
57.
Rumstadt B, Schwab M, Korth P, Samman M, Trede M: Haemorrhage after pancreatoduodenectomy. Ann Surg 1998;227:236–241.
58.
Brodsky JT, Turnbull AD: Arterial haemorrhage after pancreatoduodenectomy. The ‘sentinal bleed’. Arch Surg 1991;126:1037–1040.
59.
Van Berge Henegouwen MI, Allema JH, van Guilk TM, Verbeek PCM, Obertop H, Gouma DJ: Delayed massive haemorrhage after pancreatic and surgery. Br J Surg 1995;82:1527–1531.
60.
Shankar R, Russell RCG: Haemorrhage in pancreatic disease. Br J Surg 1989;76:863–866.
61.
Cullen JJ, Sarr MG, Ilstrup DM: Pancreatic anastomotic leak after pancreaticoduodenectomy: Incidence, significance and management. Am J Surg 1994;168:295–298.
62.
Greene BS, Loubeau JM, Peoples JB, Elliott DW: Are pancreatic anastomoses improved by duct-to-mucosa sutures? Am J Surg 1991;161:45–49.
63.
Marcus SG, Cohen H, Ranson JH: Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635–645.
64.
Grace PA, Pitt HA, Longmire WP: Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of pancreas. Br J Surg 1986;73:647–650.
65.
Sikora SS, Posner MC: Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590–1597.
66.
Di Carlo V, Chiesa R, Pontiroli A, Carlucci M, Staudacher C, Zerbi A, Cristallo M, Braga M, Pozza G: Pancreatoduodenectomy with occlusion of the residual stump by Neoprene injection. World J Surg 1989;13:105–111.
67.
Ishikawa O, Ohigashi H, Imaoka S, Teshima T, Inoue T, Sasaki Y, Iwanga T, Nakaizumi A: Concomitant benefit of preoperative irradiation in preventing pancreas fistula formation after pancreatoduodenectomy. Arch Surg 1991;126:885–889.
68.
Williams JG, Bramhall SR, Neoptolemos JP: Purse-string pancreatico-jejunostomy following pancreatic resection. Dig Surg 1997;14:183–186.
69.
Torres AJ, Landa JI, Moreno-Azcoita M, Arguello JM, Silecchia G, Castro J, Hernandez-Merlo F, Jover JM, Moreno-Gonzales E, Bailbrea JL: Somatostatin in the management of gastrointestinal fistulas. A multicentre trial. Arch Surg 1992;127:97–99.
70.
Sancho JJ, di Costanzo J, Nubiola P, Larrad A, Beguiristain A, Roqueta F, Franch G, Oliva A, Gubern JM, Sitges-Serra A: Randomised double-blind placebo-controlled trial of early octreotide in patients with post-operative enterocutaneous fistula. Br J Surg 1995;82:638–641.
71.
Nubiola P, Badia JM, Martinez-Rodenas F, Gill MJ, Segura M, Sancho JJ, Sitges-Serra A: Treatment of 27 postoperative enterocutaneous fistulas with long half-life somatostatin analogue SMS 201-995. Ann Surg 1989;210:56–58.
72.
Bassi C, Falconi M, Salvia R, Caldiron E, Butturini G, Pederzoli P: Role of octreotide in the treatment of external pancreatic pure fistula: A single-institution prospective experience. Langenbecks Arch Surg 2000;385:10–13.
73.
Alvarez C, McFadden DW, Reber HA: Complicated enterocutaneous fistula: Failure of octreotide to improve healing. World J Surg 2000;24:533–537.
74.
Sato N, Yamaguchi K, Chijiiwa K, Tanaka M: Risk analysis of fistula after pancreatic head resection. Arch Surg 1998;133:1094–1098.
75.
Van Berge Henegouwen MI, de Witt LT, van Guilk TM, Obertop H, Gouma DJ: Incidence, risk factors and treatment of pancreatic leakage after a pancreatoduodenectomy: Drainage versus resection of pancreatic remnant. J Am Coll Surg 1997;185:18–24.
76.
Farley DR, Schwall G, Trede M: Completion pancreatectomy for complications after pancreatoduodenectomy. Br J Surg 1996;83:176–179.
77.
Yeo CJ, Barry K, Sauter PK, Sostre S, Lillemoe KD, Pitt HA, Cameron JL: Erythomycin accelerates gastric emptying after pancreatoduodenectomy. Ann Surg 1993;218:229–238.
78.
Van Berge Henegouwen MI, van Guilk TM, De Witt LT, Allema JH, Rauws EJ, Obertop H, Gouma DJ: Delayed gastric emptying after standard pancreatoduodenectomy versus pylorus preserving pancreatoduodenectomy: An analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373–379.
79.
Zerbi A, Balzano G, Patuzzo R, Calori G, Braga M, Dicarlo V: Comparison between pylorus preserving and Whipple pancreatoduodenectomy. Br J Surg 1995;82:975–979.
80.
Pedrazzoli S, Di Carlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Kloppel G, Dhaene K, Michelassi F: Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: A multicentre, prospective, randomised study. Lymphadectomy Study Group. Ann Surg 1998;28:508–517.
81.
Creutzfeldt W, Lankisch PG, Folsch UR: Inhibition by somatostatin of pancreatic juice and enzyme secretion and gallbladder contraction in man induced by secretin and cholecystokinin-pancreozymin administration. Dtsch Med Wochenschr 1975;100:1135–1138.
82.
Raptis S, Schlegel W, Lehmann E, Dollinger HC, Zoupas C: Effects of somatostatin on the exocrine pancreas and the release of duodenal hormones. Metabolism 1978;27:3121–3128.
83.
Büchler M, Friess H, Klempa I, Hermanek P, Sulkowski U, Becker H, Schafmayer A, Baca I, Lorenz D, Meister R, Kremer B, Wagner P, Witte J, Zurmayer EL, Saeger HD, Rieck B, Dollinger P, Glaser K, Teichmann R, Konradt J, Gaus W, Dennler HJ, Wetzel D, Beger HG: Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–131.
84.
Pederzoli P, Bassi C, Falconi M, Camboni MG and the Italian Study Group: Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Br J Surg 1994;81:265–270.
85.
Montorsi M, Zago M, Mosca F, Capussotti L, Zotti E, Ribotta G, Fegiz G, Fissi S, Roviaro G, Peracchia A, Pivi M, Perego R, Pezzuoli G: Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: A prospective, controlled, randomised clinical trial. Surgery 1995;117:26–31.
86.
Lowy AM, Lee JE, Pisters PWT, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB: Prospective, randomised trial of octreotide to prevent pancreatic fistula after pancreatoduodenectomy for malignant disease. Ann Surg 1997;226:632–641.
87.
Yeo CJ, Cameron JL, Lillemoe KD, Sauter PK, Coleman J, Sohn TA, Campbell KA, Choti MA: Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreatoduodenectomy? Results of a prospective randomised placebo-controlled trial. Ann Surg 2000;232:419–429.
88.
Friess H, Beger HG, Sulkowski U, Becker H, Hofbauer B, Dennler HJ, Büchler MW: Randomised controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995;82:1270–1273.
89.
Gouillat C, Chipponi J, Baulieux J, Partensky C, Saric J, Gayet B: Randomised controlled multicentre trial of somatostatin infusion after pancreatoduodenectomy. Br J Surg 2001;88:1456–1462.
90.
Schaefer CJ: Cost and outcome of the Whipple procedure. Ann Surg 1995;222:211–212.
91.
Gordon TA, Burleyson GP, Tielsch JM, Cameron JL: The effect of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995;221:43–49.
92.
Rosenberg l, MacNeil P, Turcotte L: Economic evaluation of the use of octreotide for prevention of complications following pancreatic resection. J Gastrointest Surg 1999;3:225–232.
93.
Gordon TA, Bowman HM, Tielsch JM, Bass EB, Burleyson GP, Cameron JL: Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg 1998;228:71–78.
94.
Lieberman MD, Kilburn H, Lindsey M, Brennan MF: Relation of preoperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995;222:638–645.
95.
Bramhall SR, Allum WH, Jones AG, Allwood A, Cummins C, Neoptolemos JP: Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: An epidemiological study. Br J Surg 1995;84:111–115.
96.
Sand J, Nordback I: Should we concentrate pancreatoduodenectomies to fewer hospitals in Finland? Abstract. Finnish Surgical Society Annual Meeting. 1996;17:45.
97.
Birkmeyer JD, Finlayson SRG, Tosteson ANA, Sharp SM, Warshaw AL, Fisher ES: Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 1999;125:250–256.
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