Panel discussion on complex pancreatic surgery for locally advanced disease emphasizes that these operations require transplant and vascular surgery expertise, prolonged hospitalization (21-25 days), and intensive nutritional support, with speakers debating neoadjuvant chemotherapy versus upfront surgery and advocating for universal KRAS and microsatellite instability testing.
- The speaker stated that complex pancreatic resections with vascular reconstruction require 12 to 15 years of surgical experience plus transplant and vascular surgery skills, and should only be performed at specialized centers
- All patients undergoing these resections receive combined parenteral and enteral nutrition for 3 to 4 weeks targeting 2500 calories daily for men and 2000 for women, with hospital stays of at least 21 to 25 days
- The speaker does not recommend minimally invasive or robotic approaches for locally advanced disease, favoring open surgery to achieve R0 resection
- In the real world, 50% of patients do not receive adjuvant chemotherapy, leading the speaker to favor neoadjuvant treatment for patients with elevated CA 19-9 or borderline resectable disease despite lack of definitive trial evidence
- Aortic infiltration and portal vein flow less than 200 ml per minute intraoperatively are absolute contraindications to resection according to the speaker
- The panel reached consensus that every patient with locally advanced pancreatic cancer should undergo KRAS and microsatellite instability testing, with immunohistochemistry offered as a practical screening tool when germline testing access is limited
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