Pancreatic cancer surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Sudarshana Datta, MD [3]

Overview

Complete (R0) surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC). It is appropriate only for localized disease and is one part of multimodality therapy that nearly always includes systemic chemotherapy.[1][2] A multidisciplinary team assigns resectability from pancreatic-protocol imaging. The four categories are resectable, borderline resectable, locally advanced, and metastatic, and they are defined mainly by tumor contact with the celiac axis, superior mesenteric artery, common hepatic artery, superior mesenteric vein, and portal vein.[3][4]

For resectable disease, the standard approach is upfront resection followed by adjuvant chemotherapy. For borderline resectable disease, neoadjuvant therapy is given before resection.[3][5] Venous resection with reconstruction is accepted when it achieves R0. Arterial resection is reserved for selected responders at expert centers.[3][6] Outcomes depend strongly on hospital volume.[7] Metastatic and unconvertible locally advanced disease are managed with endoscopic or surgical palliation, not resection.[3]

Surgery

Resectability assessment

  • Determine resectability at a multidisciplinary tumor board.
  • Use a structured radiology reporting template.
    • "Abutment" means ≤180° circumferential tumor–vessel contact.
    • "Encasement" means >180° contact or vessel contour deformity.[4]
  • Tumor size alone is not a criterion for unresectability. Contiguous organ involvement that can be resected en bloc does not by itself preclude resection.[3]
  • The 2017 International Association of Pancreatology consensus adds two further dimensions to anatomy:[8]
    • Biological factors, such as markedly elevated CA 19-9
    • Conditional (physiological) factors, such as performance status
  • Locally advanced disease is not necessarily permanently unresectable. A subset of patients becomes resectable after neoadjuvant therapy.[3]
NCCN resectability criteria for pancreatic ductal adenocarcinoma (summary)
Category Arterial (CA, SMA, CHA) Venous (SMV, PV)
Resectable No arterial tumor contact No contact, or ≤180° contact without vein contour irregularity
Borderline resectable Head/uncinate: CHA contact without extension to the CA or hepatic artery bifurcation; SMA contact ≤180°; contact with variant arterial anatomy
Body/tail: CA contact ≤180° 		Contact >180°, or ≤180° with contour irregularity or vein thrombosis, with suitable vessel proximal and distal to the site of involvement for reconstruction; IVC contact
Locally advanced SMA or CA contact >180°; CA contact with aortic involvement Unreconstructible SMV/PV involvement or occlusion
Metastatic Any distant metastasis, including non-regional lymph node metastasis, regardless of local anatomy

CA, celiac axis; SMA, superior mesenteric artery; CHA, common hepatic artery; SMV, superior mesenteric vein; PV, portal vein; IVC, inferior vena cava. Adapted from NCCN v4.2026.[3]

Sequencing of surgery and systemic therapy

Category Recommended approach Key evidence
Resectable Upfront resection, then adjuvant chemotherapy to complete about 6 months of therapy. Neoadjuvant therapy is an option, particularly with high-risk features: markedly elevated CA 19-9, large primary tumor, bulky regional lymph nodes, excessive weight loss, or severe pain.[3] NORPACT-1 (phase 2): neoadjuvant FOLFIRINOX did not improve overall survival over upfront surgery for resectable pancreatic head cancer.[9] SWOG S1505 (phase 2): neither perioperative regimen was clearly superior.[10]
Borderline resectable Neoadjuvant chemotherapy with or without radiotherapy, then restaging, resection of responders, and completion of about 6 months of total perioperative therapy.[3] PREOPANC long-term analysis: neoadjuvant gemcitabine-based chemoradiotherapy improved 5-year overall survival (20.5% vs 6.5%; HR 0.73, 95% CI 0.56–0.96). The benefit was most pronounced in borderline resectable disease.[5] ESPAC-5 (phase 2) also supported a neoadjuvant approach.[11]
Locally advanced Induction systemic therapy with or without chemoradiation. Consider resection only after objective response, at an experienced center.[3] Conversion to resection is possible in a subset of patients.[3]
Metastatic No resection. Systemic therapy and symptom-directed palliation.[3] —
  • Neoadjuvant regimen
    • In the phase 3 PREOPANC-2 trial, overall survival did not differ between neoadjuvant FOLFIRINOX and neoadjuvant gemcitabine-based chemoradiotherapy (median 21.9 vs 21.3 months; HR 0.88, 95% CI 0.69–1.13). Both regimens are acceptable.[12]
    • In the phase 3 PACT-21 CASSANDRA trial, preoperative PAXG (cisplatin, nab-paclitaxel, capecitabine, gemcitabine) improved event-free survival over mFOLFIRINOX in patients aged 18–75 years (median 16.0 vs 10.2 months; HR 0.63, 95% CI 0.47–0.84).[13]
    • Regimen details belong in the medical therapy microchapter.
  • Restaging after neoadjuvant therapy
    • Base the decision to operate on overall response:[3]
      • Radiologic response (RECIST)
      • Biochemical response (CA 19-9)
      • Metabolic response (FDG-PET)
    • Do not base the decision on persistent vascular contact alone. CT cannot distinguish treatment-related fibrosis from viable tumor.
    • The more complex the planned operation, the greater the response needed to justify it.
    • The final determination is often made intraoperatively.
  • CA 19-9 limitations
    • Interpret only after biliary decompression; obstruction and cholangitis falsely raise CA 19-9.
    • CA 19-9 is uninformative in Lewis antigen–negative patients.[3]
  • Adjuvant delivery
    • Completing systemic therapy is a key survival determinant.
    • Giving chemotherapy first ensures it is delivered to patients whose postoperative recovery would otherwise delay or prevent adjuvant therapy.[3]

Resectional procedures

Procedure Tumor location / indication Key technical and oncologic points
Pancreatoduodenectomy (classic or pylorus-preserving Whipple procedure) Head and uncinate process En bloc removal of the pancreatic head, duodenum, proximal jejunum, distal common bile duct, gallbladder, and (classic) distal stomach. Reconstruction is by pancreatico-, hepatico-, and gastro/duodenojejunostomy. Pylorus-preserving and classic resections have comparable outcomes.[14] Dissect the SMA (uncinate/retroperitoneal) margin meticulously. Send frozen sections of the pancreatic neck and bile duct margins, with further excision if tumor is within 5 mm.[3]
Distal pancreatectomy with en bloc splenectomy Body and tail Spleen preservation is not appropriate for adenocarcinoma. Dissect to the CA/SMA adventitia, with venous resection as needed. En bloc resection beyond the spleen may be needed in up to 40% of patients to achieve R0.[3]
Total pancreatectomy Extensive or multifocal disease, or when required for a negative margin Not a routine cancer operation. It causes complete exocrine pancreatic insufficiency and insulin-dependent, labile diabetes mellitus.[15]
Extended resections for neck tumors Pancreatic neck, anterior to the SMV/PV May require extended pancreatoduodenectomy, extended distal pancreatectomy, or total pancreatectomy. Anticipate SMV/PV involvement. The required extent is often determined only intraoperatively.[3]
  • Margins
    • A tumor-free margin of ≥1 mm is increasingly used as the clinically relevant R0 definition, although definitions vary internationally.[15]
  • Lymphadenectomy
    • Extended lymphadenectomy does not improve survival and increases morbidity compared with standard lymphadenectomy.[16]
  • Recurrence
    • Recurrence occurs in about 70–80% of patients after curative-intent resection, most often at distant sites.
    • Median recurrence-free survival is about 12 months.[15]

Vascular resection and reconstruction

  • Venous (SMV/PV) resection
    • An oncologically appropriate extension of pancreatoduodenectomy when it allows R0 resection.[3]
    • Reconstruction options:
      • Primary venorrhaphy or patch
      • Segmental resection with end-to-end anastomosis
      • Interposition graft: internal jugular, saphenous, or femoral vein, or allograft
    • It is associated with greater operative complexity, more blood loss, and a higher risk of positive margins.[3]
    • Contemporary series report acceptable short-term mortality, with survival similar to standard resection when R0 is achieved.[17][18]
  • Arterial (CHA, CA, SMA) resection
    • Carries substantially higher morbidity and mortality than venous resection.
    • Restrict to highly selected patients with objective response to neoadjuvant therapy, at centers experienced in arterial reconstruction.
    • Counsel patients explicitly that the oncologic benefit is unproven.[3]
    • In a 10-year single-center series of 715 patients, vascular resection was not independently associated with oncologic outcome after adjustment for perioperative therapy.[19]
  • Arterial divestment
    • Periadventitial, artery-sparing dissection is an emerging alternative to arterial resection in selected patients.[18]
  • 2019 French recommendations[6]
    • Give neoadjuvant therapy before any planned vascular resection.
    • Avoid pancreatoduodenectomy with SMA resection when the periarterial frozen section is positive.

Minimally invasive surgery

  • Distal pancreatectomy
    • Minimally invasive (laparoscopic or robotic) distal pancreatectomy is an accepted approach.
    • In the international DIPLOMA randomized trial, it was noninferior to open surgery for radical (R0) resection of resectable PDAC.[20]
    • Advantages include less blood loss and a shorter length of stay.[21]
  • Pancreatoduodenectomy
    • The LEOPARD-2 trial was stopped early because of excess complication-related mortality in the laparoscopic arm.[22]
    • Meta-analyses show longer operative time, less blood loss, and shorter stay, with similar morbidity, mortality, R0 rates, and nodal yield.[23]
    • DIPLOMA-2 randomized 288 patients at 14 high-volume European centers.[24] Minimally invasive pancreatoduodenectomy was noninferior for 90-day complications and gave faster functional recovery.[25]
    • Randomized oncologic data for robotic pancreatoduodenectomy in pancreatic cancer are pending (DIPLOMA-2x2).[24]
    • Perform minimally invasive pancreatoduodenectomy only in experienced, high-volume programs.

Hospital volume and centralization

  • Volume–outcome evidence
    • Meta-analysis: higher hospital volume is associated with lower postoperative mortality (OR 0.35) and fewer major complications.
    • High surgeon volume is also associated with lower mortality (OR 0.29).[7]
  • Volume thresholds
    • NCCN recommends resection at institutions performing at least 15–20 pancreatic resections per year.[3]
    • The best outcomes are reported for surgeons performing more than 20 pancreatoduodenectomies per year.[2]
  • Hospital versus surgeon volume
    • For short-term outcomes, hospital volume appears to outweigh individual surgeon volume, likely reflecting multidisciplinary rescue of complications.[26]
  • Timing versus volume
    • Delayed resection at a high-volume center was associated with lower mortality than earlier resection at a low-volume center (HR 0.81).[27]
  • Limits of volume as a quality marker
    • Outcomes vary about 2-fold even among surgeons who meet volume standards.[28]
    • Target-trial emulation suggests confounding of the volume–outcome association.[29]

Perioperative morbidity and mortality

At high-volume centers, operative mortality is below 4–5%, but overall morbidity remains 40–50%.[2]

Complication Approximate frequency Notes
Postoperative pancreatic fistula ~9–18% after pancreatoduodenectomy Main driver of morbidity. Also the leading complication after distal pancreatectomy.[16][2]
Delayed gastric emptying ~10–23% More common after pancreatoduodenectomy.[16]
Post-pancreatectomy hemorrhage ~1–10% Late (sentinel) bleeding often signals pseudoaneurysm associated with a fistula.[16]
Intra-abdominal abscess, bile leak, wound infection Variable —[2]
Chyle leak; new or worsened endocrine/exocrine insufficiency Variable Characteristic of distal pancreatectomy.[2]
Insulin-dependent diabetes and complete exocrine insufficiency Universal Obligatory after total pancreatectomy.[15]

Preoperative biliary drainage

  • Do not routinely drain the biliary tree before upfront resection.
    • In a randomized trial, routine preoperative drainage increased serious complications without benefit compared with early surgery.[30]
  • Reserve drainage for the following situations, using a self-expanding metal stent (SEMS):[3]

Palliative surgical and endoscopic procedures

Problem Preferred approach Alternatives
Malignant biliary obstruction Endoscopic SEMS. Plastic stents only when predicted survival is <3 months.[3] Percutaneous transhepatic drainage; open or laparoscopic biliary-enteric bypass
Gastric outlet obstruction Gastrojejunostomy (open or laparoscopic) or enteral stent; place an enteral stent only after assured biliary drainage.[3] EUS-guided gastrojejunostomy at high-volume centers; venting percutaneous endoscopic gastrostomy
Tumor-related pain Early palliative care referral; opioids; EUS-guided celiac plexus neurolysis.[3] Stereotactic body radiation therapy; high-intensity focused ultrasound; intrathecal drug delivery for refractory pain

Areas of uncertainty

  • Neoadjuvant therapy for anatomically resectable disease
    • This remains unresolved; randomized phase 2 trials have not shown a survival benefit.[9][10]
    • Phase 3 trials are ongoing.
  • Optimal neoadjuvant regimen and role of radiotherapy
    • Both are undefined.[12][13]
    • Consolidative chemoradiation improves local control and margin negativity, but its overall survival benefit is inconsistent.[3]
  • Arterial resection and divestment
    • Oncologic benefit is unproven.
    • Classification of celiac axis involvement in body/tail tumors (distal pancreatectomy with celiac axis resection) differs between institutions and guideline panel members.[3][31]
  • Volume as a quality metric
    • The volume–outcome association is strong but partly confounded.
    • Regionalization involves trade-offs in access and travel.[29][32]
  • Robotic pancreatoduodenectomy
    • It lacks randomized oncologic outcome data.[24]

Common pitfalls

  • Deciding resectability
    • Calling tumors unresectable because of size or isolated reconstructible venous contact, rather than referring to an expert center.[3]
    • Judging resectability after neoadjuvant therapy by persistent vascular contact on CT alone.[3]
  • Treatment sequencing
    • Operating upfront on borderline resectable disease instead of giving neoadjuvant therapy first.[5]
    • Pursuing arterial resection without neoadjuvant response or adequate counseling.[6]
  • Preoperative management
    • Routinely stenting the bile duct before upfront resection.[30]
    • Interpreting CA 19-9 during jaundice or cholangitis, or in Lewis antigen–negative patients.[3]
  • Operative technique
    • Preserving the spleen during distal pancreatectomy for adenocarcinoma.[3]
    • Omitting frozen-section assessment of the pancreatic neck and bile duct margins.[3]
  • Choice of center
    • Attempting resection at a low-volume center, which carries higher rates of positive margins and failure to rescue complications.[7]

References

  1. ↑ Mizrahi JD, Surana R, Valle JW, Shroff RT (2020). "Pancreatic cancer". Lancet. 395 (10242): 2008–2020. doi:10.1016/S0140-6736(20)30974-0.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Park W, Chawla A, O'Reilly EM (2021). "Pancreatic cancer: a review". JAMA. 326 (9): 851–862. doi:10.1001/jama.2021.13027.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 3.23 3.24 3.25 3.26 3.27 3.28 3.29 3.30 3.31 3.32 3.33 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Pancreatic Adenocarcinoma. Version 4.2026. NCCN
  4. ↑ 4.0 4.1 Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM (2014). "Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association". Radiology. 270 (1): 248–60. doi:10.1148/radiol.13131184. PMID 24354378.
  5. ↑ 5.0 5.1 5.2 Versteijne E, van Dam JL, Suker M, Janssen QP, Groothuis K, Akkermans-Vogelaar JM, et al. (2022). "Neoadjuvant chemoradiotherapy versus upfront surgery for resectable and borderline resectable pancreatic cancer: long-term results of the Dutch randomized PREOPANC trial". J Clin Oncol. 40 (11): 1220–1230. doi:10.1200/JCO.21.02233. PMID 35084987 Check |pmid= value (help).
  6. ↑ 6.0 6.1 6.2 Delpero JR, Sauvanet A (2020). "Vascular resection for pancreatic cancer: 2019 French recommendations based on a literature review from 2008 to 6-2019". Front Oncol. 10: 40. doi:10.3389/fonc.2020.00040. PMC 7010716 Check |pmc= value (help).
  7. ↑ 7.0 7.1 7.2 Fischer C, Alvarico SJ, Wildner B, Schindl M, Simon J (2023). "The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment". HPB (Oxford). 25 (4): 387–399.
  8. ↑ Isaji S, Mizuno S, Windsor JA, Bassi C, Fernández-del Castillo C, Hackert T, et al. (2018). "International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017". Pancreatology. 18 (1): 2–11. doi:10.1016/j.pan.2017.11.011. PMID 29191513.
  9. ↑ 9.0 9.1 Labori KJ, Bratlie SO, Andersson B, Angelsen JH, Biörserud C, Björnsson B, et al. (2024). "Neoadjuvant FOLFIRINOX versus upfront surgery for resectable pancreatic head cancer (NORPACT-1): a multicentre, randomised, phase 2 trial". Lancet Gastroenterol Hepatol. 9 (3): 205–217. doi:10.1016/S2468-1253(23)00405-3. PMID 38237621 Check |pmid= value (help).
  10. ↑ 10.0 10.1 Sohal D, Duong M, Ahmad SA, Gandhi NS, Beg MS, Wang-Gillam A, et al. (2021). "Efficacy of perioperative chemotherapy for resectable pancreatic adenocarcinoma: a phase 2 randomized clinical trial". JAMA Oncol. 7 (3): 421–427. doi:10.1001/jamaoncol.2020.7328. PMID 33475684 Check |pmid= value (help). Vancouver style error: initials (help)
  11. ↑ Ghaneh P, Palmer D, Cicconi S, Jackson R, Halloran CM, Rawcliffe C, et al. (2023). "Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial". Lancet Gastroenterol Hepatol. 8 (2): 157–168. doi:10.1016/S2468-1253(22)00348-X. PMID 36521500 Check |pmid= value (help).
  12. ↑ 12.0 12.1 Janssen QP, van Dam JL, van Bekkum ML, Bonsing BA, Bos H, Bosscha KP, et al. (2025). "Neoadjuvant FOLFIRINOX versus neoadjuvant gemcitabine-based chemoradiotherapy in resectable and borderline resectable pancreatic cancer (PREOPANC-2): a multicentre, open-label, phase 3 randomised trial". Lancet Oncol. 26 (10): 1346–1356. doi:10.1016/S1470-2045(25)00363-8. PMID 40945523 Check |pmid= value (help).
  13. ↑ 13.0 13.1 Reni M, Macchini M, Orsi G, Procaccio L, Malleo G, Carconi C, et al. (2025). "Preoperative mFOLFIRINOX versus PAXG for stage I–III resectable and borderline resectable pancreatic ductal adenocarcinoma (PACT-21 CASSANDRA): results of the first randomisation analysis of a randomised, open-label, 2 × 2 factorial phase 3 trial". Lancet. 406 (10522): 2945–2956. doi:10.1016/S0140-6736(25)01685-X.
  14. ↑ Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, Diener MK (2016). "Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma". Cochrane Database Syst Rev. 2: CD006053. doi:10.1002/14651858.CD006053.pub6. PMID 26905229.
  15. ↑ 15.0 15.1 15.2 15.3 Roth S, Apte M, Balachandran VP, Biffi G, Conroy T, Cukierman E, et al. (2026). "Pancreatic cancer". Nat Rev Dis Primers. 12: 23. doi:10.1038/s41572-026-00699-6.
  16. ↑ 16.0 16.1 16.2 16.3 Staerkle RF, Vuille-dit-Bille RN, Soll C, Troller R, Samra J, Puhan MA, Breitenstein S (2021). "Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma". Cochrane Database Syst Rev. 1 (1): CD011490. doi:10.1002/14651858.CD011490.pub2.
  17. ↑ Jabłońska B, Król R, Mrowiec S (2022). "Vascular resection in pancreatectomy—is it safe and useful for patients with advanced pancreatic cancer?". Cancers (Basel). 14 (5): 1193. doi:10.3390/cancers14051193. PMC 8909590 Check |pmc= value (help).
  18. ↑ 18.0 18.1 Moris D, Nguyen BM, Kroemer A, Weinberg B, Unger KR, Haddad NG, et al. (2026). "Vascular resection, reconstruction, and divestment in pancreatoduodenectomy: expanding boundaries in pancreatic cancer surgery". Cancers (Basel). 18 (4): 577. doi:10.3390/cancers18040577.
  19. ↑ Henault D, Kunde H, Zatzman C, Bevacqua D, Arshinoff D, Cleary SP, et al. Vascular resection for pancreas cancer: ten-year real-world experience from a single high-volume center. Abstract presented at: ASCO Gastrointestinal Cancers Symposium; 2024. ASCO abstract
  20. ↑ Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, et al. (2023). "Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial". Lancet Reg Health Eur. 31: 100673. doi:10.1016/j.lanepe.2023.100673. PMC 10339208 Check |pmc= value (help). PMID 37457332 Check |pmid= value (help).
  21. ↑ Nießen A, Hackert T (2022). "State-of-the-art surgery for pancreatic cancer". Langenbecks Arch Surg. 407 (2). doi:10.1007/s00423-021-02362-y. PMC 8933301 Check |pmc= value (help).
  22. ↑ van Hilst J, de Rooij T, Bosscha K, Brinkman DJ, van Dieren S, Dijkgraaf MG, et al. (2019). "Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial". Lancet Gastroenterol Hepatol. 4 (3): 199–207. doi:10.1016/S2468-1253(19)30004-4. PMID 30685489.
  23. ↑ Sattari SA, Sattari AR, Makary MA, Hu C, He J (2023). "Laparoscopic versus open pancreatoduodenectomy in patients with periampullary tumors: a systematic review and meta-analysis". Ann Surg. 277 (5): 742–755. doi:10.1097/SLA.0000000000005785.
  24. ↑ 24.0 24.1 24.2 de Graaf N, Emmen A, Ramera M, Björnsson B, Boggi U, Bruna CL, et al. (2023). "Minimally invasive versus open pancreatoduodenectomy for pancreatic and peri-ampullary neoplasm (DIPLOMA-2): study protocol for an international multicenter patient-blinded randomized controlled trial". Trials. 24: 665. doi:10.1186/s13063-023-07657-7. PMC 10571285 Check |pmc= value (help). Vancouver style error: initials (help)
  25. ↑ European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS). Minimally invasive versus open pancreatoduodenectomy for pancreatic and peri-ampullary neoplasm (DIPLOMA-2): an international multicenter patient-blinded randomized trial. NEJM Evidence. 2025.
  26. ↑ Patel DJ, Cotler JH, Palis B, Yang AD, Schmidt CM, Weigel RJ, et al. (2026). "Assessing the interplay of operative volume at the hospital and surgeon level for pancreatic cancer". HPB (Oxford). doi:10.1016/j.hpb.2026.07.007. PMID 42542416 Check |pmid= value (help).
  27. ↑ Sakowitz S, Yamashita M, Hammons M, Donahue TR. Improved survival with delayed surgery at high-volume centers versus early surgery at low-volume centers for pancreatic cancer. Ann Surg Oncol. 2026 Jan 15. [Epub ahead of print]
  28. ↑ Aquina CT, Becerra AZ, Fleming FJ, Cloyd JM, Tsung A, Pawlik TM, Ejaz A (2021). "Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery". Cancer. 127 (21): 4059–4071. doi:10.1002/cncr.33766.
  29. ↑ 29.0 29.1 Madenci AL, Wanis KN, Cooper Z, Martinez-Camblor P, Zhang M, Ramirez SR, et al. (2022). "Comparison of mortality risk with different surgeon and hospital operative volumes among individuals undergoing pancreatectomy by emulating target trials in US Medicare beneficiaries". JAMA Netw Open. 5 (3): e221766. doi:10.1001/jamanetworkopen.2022.1766. PMC 8914572 Check |pmc= value (help).
  30. ↑ 30.0 30.1 van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, et al. (2010). "Preoperative biliary drainage for cancer of the head of the pancreas". N Engl J Med. 362 (2): 129–37. doi:10.1056/NEJMoa0903230. PMID 20071702.
  31. ↑ Kulkarni NM, Soloff EV, Tolat PP, Sangster GP, Fleming JB, Brook OR, et al. (2020). "White paper on pancreatic ductal adenocarcinoma from Society of Abdominal Radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease". Abdom Radiol (NY). 45 (3): 716–728. doi:10.1007/s00261-019-02289-5. PMID 31748823.
  32. ↑ Acher AW, Weber SM, Pawlik TM (2022). "Does the volume-outcome association in pancreas cancer surgery justify regionalization of care? A review of current controversies". Ann Surg Oncol. 29 (2): 1257–1268. doi:10.1245/s10434-021-10765-w.
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