Survival following pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has clearly improved over the past several decades. Evidence from the Johns Hopkins Hospital series indicates that it has continued to improve from the 1970s to the 1980s to the 1990s. The reasons for this improvement are multiple. Between the 1970s and 1980s a decrease in operative and hospital mortality clearly played an important role. In addition, the markedly decreased number of blood transfusions given during pancreaticoduodenectomy in the 1980s probably contributed to the improvement in long-term survival. Positive resection margins were more common in the 1970s than in the 1980s and 1990s, and that probably played a major role. It is unlikely, however, that any of these factors played a role in the improvement in survival between the 1980s and 1990s. Perhaps the increasing use of adjuvant therapy is primarily responsible for the most recent improvement. Whatever the reasons, more patients are surviving pancreaticoduodenectomy, and among those patients who survive the operation, more people are surviving for prolonged periods. It is clear that we now have an effective operation for patients with adenocarcinoma of the head of the pancreas who are detected early, prior to lymph node spread. If we can find a tumor marker that allows us to identify more patients prior to nodal spread, substantial improvement in survival will accrue. In addition, better adjuvant therapy is needed, as the adjuvant regimens used today, which clearly prolong survival, almost certainly can be improved upon.
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