Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics

Re-organisation of oesophago-gastric cancer services in England and Wales: a follow-up assessment of progress and remaining challenges.

BACKGROUND: This study is an update on an earlier article in 2007 to assess the implementation of the Cancer Plan reform strategy in England and Wales. FINDINGS: A national online survey to upper gastro-intestinal leads at network and trust level. The questionnaire was designed based on existing clinical practice guidelines and addressed governing principles and operational procedures related to the delivery of cancer care. It was sent in January 2012 to upper gastro-intestinal network and trusts leads at all cancer networks and acute NHS organisations in England and Wales. Responses were received from 100% of Cancer Networks and 91% of NHS organisations. Centralisation of surgery has improved with all but two trusts (5.4%) now meeting the minimum staffing level for oesophago-gastric cancer surgery. This is a substantial improvement since the 2007 survey when 21 trusts (46.7%) did not meet this requirement. The use of formal assessment for nutritional needs has improved, too. In 2007, the involvement of the palliative care team in multi-disciplinary teams was poor. While this has improved, 27 trusts (19.7%) still report that none of the palliative care team members routinely attend the multi-disciplinary team discussion. CONCLUSIONS: The survey demonstrates improved compliance with organisational recommendations since the last assessment in 2007. Centralisation of surgery has improved and is nearly fully compliant with the reform strategy. Areas that require further improvement are nutritional support and inclusion of palliative care in multi-disciplinary team meetings