Management of resectable and borderline resectable disease: Surgery

Surgery remains the mainstay of the multimodality treatment plan for anatomically and borderline resectable (AR and BR) pancreatic adenocarcinoma (PDAC). A successful operation is one in which a well-selected patient is cleared of localized disease and also returns to his/her expected baseline function at a reasonable time. Clinical staging for anatomically and borderline resectable PDAC is based on the MD Anderson Cancer Center A-B-C system, which stratifies patients using tumor anatomy ("A"), tumor biology ("B"), and patient condition ("C"). The preoperative time period can be used for neoadjuvant therapy which allows for treatment of micro-metastatic disease which is ubiquitous in almost all PDAC cases and patient medical optimization. During the operation, there are operative and oncologic goals which include safe, complication-free surgery and margin-negative resection. Postoperative care with enhanced recovery pathways is the standard of care so that patients can resume their baseline quality of life and receive further chemotherapy if indicated. Quality measures which focus on both surgical (complications) and oncologic (margins) are required to drive further national improvements in this high-risk operation.