The value of extended lymphadenectomy is controversial. There have been many debates about the results of extended lymphadenectomy for adenocarcinoma of the pancreatic head [10]. The conclusion of these articles is that extended lymphadenectomy does not benefit long-term survival and no further studies are required to assess this issue.

Many authors have discussed the type of anastomosis in the pancreatic and alimentary tracts. Two reconstructions are used: pancreatogastrostomy and pancreaticojejunostomy. The main issue is the prevalence of pancreatic fistulas, the „Achilles’ heel of pancreatic surgery”. In this regard, many studies have been conducted without evidence of the superiority of one type of anastomosis over another. Berger et al. [11] found a lower rate of fistulas with invagination of the pancreas in the jejunal loop with respect to the duct to the jejunum anastomosis (Fig. 6.5). Peng et al. described promising method called a „binding pancreaticojejunostomy” [12]: an end-to-end anastomosis with invagination of the pancreas in a jejunal loop in which the mucosa was previously cauterized. Somatostatin seems to have a prophylactic function with respect to postoperative morbidity and fistula formation [13].

With regard to stenting of the MPD, external stents seem to have a better outcome in terms of postoperative complications and pancreatic fistulas compared with internal stents or no stent, but further studies are required [14]. In conclusion, given the relatively high rate of complications in this type of surgery, the choice of pancreatic anastomotic method should be based on individual experience, and the best anastomosis after PD is based upon the preference and experience of the surgeon [15].

Several studies have been conducted to assess the results of vascular resections to achieve R0 margins during PD for advanced adenocarcinoma with vascular involvement. Even if vascular resection can be achieved safely, the overall 3-year survival in PD with vascular resection shows no differences from PD without vascular resection [16]. In a retrospective analysis of 3,582 patients undergoing PD for malignant disease, Castleberry et al. [17] demonstrated increased 30-day morbidity and mortality in PD associated with vascular resections.

Laparoscopic approaches to pancreatic-head tumors are controversial. The criticism originates from the prolonged operating time and the often reduced accuracy in dissection and reconstruction time. Several authors have reported small series of laparoscopic PD, and showing no substantial advantages of minimally invasive surgery (MIS). Looking to the future, widespread and less expensive propagation of robotic-assisted laparoscopic methods could provide a sense of MIS approach in this field.

In a recent study with 15 patients [18], the morbidity, mortality and incidence of pancreatic fistulas seemed to be similar to those reported for open or laparoscopic surgery, as well as the number of lymph nodes collected. Compared with a laparoscopic approach, robotic surgery seems to have a lower conversion rate, blood loss and operating time as well as better oncological results [19]. MIS applied to the treatment of distal tumors of the pancreas (body and tail) has shown encouraging results primarily due to increasing experiences of many researchers worldwide.

In the early days of MIS for distal pancreatic lesions, the indications were limited strictly to benign and borderline diseases (cystic tumors, neuroendocrine tumors). However, authors are now reporting on malignant tumors treated by this approach. The advantages of MIS are less blood loss, reduced postoperative morbidity and hospital stay.

Venkat et al., in their meta-analysis of 1,814 patients, reported similar oncological results and margin-free resections [20]. Moreover, recent retrospective studies from Fox et al. highlight the lower cost (postoperative and total) in the laparoscopic group compared with open pancreatectomy [21].

A matter of concern is the possibility of spleen preservation, which seems to be higher in MIS of the distal pancreas. Two methods can be used to save the spleen. The first involves dissecting out the splenic artery and vein with division between the pancreas and the splenic artery and vein. The second is by resecting the splenic vessels along with the pancreas but with careful preservation of the vascular collaterals in the splenic hilum, which allows the spleen to survive on the short gastric vessels (Warshaw method). Only retrospective studies are available regarding this issue. However, these studies seem to confirm that spleen preservation gives a lower morbidity rate compared with splenectomy associated with this type of pancreatic resection. Distal pancreatectomy plus splenectomy seems to impair postoperative pancreatic leaks, fatigue, cold or flu. Tsiouris et al. noticed more pancreatic leaks in a spleen-preserving group [22]. With regard to the method (splenic vessels resection vs vessel preservation), postoperative complications were not different between the two groups; a low occurrence of perigastric varices was detectable in the splenic vessel resection group.

In distal pancreatectomies, robotic-assisted laparoscopic surgery seems to allow promising results in terms of the accuracy of surgical field dissection, harvesting of lymph nodes, blood loss and postoperative recovery due to the well-known advantages of robotic movements. In the next few years we will surely observe propagation of these methods, and obtain results from larger series.

Some investigators have assessed the feasibility and complications of radiofrequency ablation (RFA) applied to pancreatic tumors that are suitable for complete resection. Complications are related mainly to thermal injuries to the nearest organs, such as the biliary tract, duodenum, portal vein and transverse colon, and the prevalence of such injuries is ≈24%. Promising results have come from the association of RFA with radiochemotherapy or systemic chemotherapy: median survival is 25.6 months with an intra-abdominal morbidity rate of 26.2% [23].