INTRODUCTION

Approximately 45,220 people develop exocrine pancreatic cancer each year in the United States, and almost all are expected to die from the disease [1]. The majority of these tumors (85 percent) are adenocarcinomas arising from the ductal epithelium. (See "Pathology of exocrine pancreatic neoplasms".)

Surgical resection is the only potentially curative treatment. Unfortunately, because of the late presentation of the disease, only 15 to 20 percent of patients are candidates for pancreatectomy. The prognosis of pancreatic cancer is poor even in those with potentially resectable disease, and despite progress in surgical techniques and adjuvant therapy, there is little evidence that outcomes are improving over time. (See 'Results' below and "Adjuvant and neoadjuvant therapy for exocrine pancreatic cancer".)

The surgical management of cancers of the exocrine pancreas will be reviewed here. The clinical manifestations, diagnosis and pathologic features, adjuvant and neoadjuvant approaches are discussed separately, as is the management of tumors arising in the endocrine pancreas (islet cell tumors). (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer" and "Adjuvant and neoadjuvant therapy for exocrine pancreatic cancer" and "Classification, epidemiology, clinical presentation, localization, and staging of pancreatic neuroendocrine tumors (islet-cell tumors)".)

PREOPERATIVE STAGING

Several diagnostic studies are available to determine the tumor stage. Disease that is limited to the pancreas and peripancreatic nodes (stage I-IIB disease, (table 1) [2]) is most likely to be cured by radical resection. Absolute contraindications for resection include the presence of metastases in the liver, peritoneum, omentum, or any extraabdominal site.  Other indications of unresectability include encasement (more than one-half of the vessel circumference) or occlusion/thrombus of the superior mesenteric vein (SMV) or the SMV-portal vein confluence, and direct involvement of the superior mesenteric artery (SMA), inferior vena cava, aorta, celiac axis, or hepatic artery, as defined by the absence of a fat plane between the low density tumor and these structures on CT scan. This topic is discussed in detail elsewhere. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer".)

Tumors with limited involvement of the major peripancreatic vessels such as the superior mesenteric vein, portal vein, or superior mesenteric artery may be technically resectable. The impact on long-term prognosis is controversial. (See 'Vascular evaluation' below and 'Vascular resection' below.)