In 2013, pancreatic cancer was the 10th most commonly diagnosed cancer in
Australia, with an incidence of 2,865 people in that year, commanding a cost
of up to $1,676,300 per person to the healthcare system (1,2). Carcinoma of
the pancreas and periampullary region continues to be associated with a very
poor prognosis. This is highlighted by the close parallel between incidence
and mortality (3). Individuals diagnosed with pancreatic cancer have an
overall five year survival of <7% (2,4). The poor prognosis is partly attributed to the insidious disease progression where patients often remain asymptomatic until it reaches an advanced stage causing delayed diagnosis (3). The majority of pancreatic neoplasms comprise of pancreatic ductal adenocarcinomas, accounting for up to 85-90% of all pancreatic neoplasms (3). Approximately 80% of cases occur in patients 60-80 years with rare cases below the age of 40 years (2,3). The incidence of pancreatic carcinoma is slightly higher in men with a male/female ratio of 1.6 (2). Although the cause of pancreatic cancer remains unclear, the most notable association is related to tobacco smoking (3). It has been reported to carry up to a three-fold relative risk that linearly increases with the number of pack-years smoked (3). Together with other reported associations such as chronic pancreatitis and diabetes mellitus, it accounts for approximately one-quarter to one-third of cases (3). In addition, a number of hereditary –1– cancer syndromes, hereditary pancreatitis, Peutz-Jeghers syndrome and cystic fibrosis have also been identified as risk factors (5,6). The majority of pancreatic ductal adenocarcinomas are found in the head of the gland and the remainder occur in the body and/or tail (3). Unfortunately, by the time of resection, the carcinoma has often spread out of the pancreas (3). Pancreatic cancer is usually aggressive, with perineural, vascular and lymphatic spread with early distant metastases into nearby organs or peritoneum (3). Due to the advanced nature of pancreatic carcinoma, the method of surgical resection is usually a significant undertaking. Surgical resection remains the only potentially curative treatment of pancreas and periampullary cancer. Following surgical resection and adjuvant therapy for pancreatic cancer, median survival has been reported to increase to an estimated 22 months, with a 5-year survival of 15-25% (4). For malignancies of the head of the pancreas and periampullary region, pancreaticoduodenectomy (PD) is the procedure of choice. Since the first successful procedure by Whipple and Parsons in 1935, the modern PD, has evolved into a complex, high-risk one stage surgical procedure involving the removal of the head of the pancreas, the duodenum including the duodenal papilla or ampulla of vater, the proximal jejunum, common bile duct, gallbladder and a partial gastrectomy (Figure 1-1). Variations of the conventional procedure include pylorus preserving and subtotal stomach preserving methods. Subsequent reconstruction involves the formation of both a pancreaticojejunostomy and a hepaticojejunostomy. Historically this was carried out as an open procedure however, of late, there has been an increasing move to more minimally invasive techniques. 

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