ORIGINAL ARTICLE R2 resection in pancreatic cancer—does it make sense? Jörg Köninger & Moritz N. Wente & Beat P. Müller-Stich & Francesco F. di Mola & Carsten N. Gutt & Ulf Hinz & Michael W. Müller & Helmut Friess & Markus W. Büchler Received: 23 November 2007 / Accepted: 31 January 2008 / Published online: 29 February 2008 # Springer-Verlag 2008 Abstract Background The goal of surgical treatment in patients with pancreatic cancer is the complete resection of tumor tissue; however, the intraoperative appraisal of resectability can be difficult. Extensive surgical exploration for definitive clear resectability may lead to R2 resections in single cases. Patients We analyzed 38 patients with pancreatic cancer with remaining macroscopic tumor tissue after pancreatic resection, as R0 resection was not possible. Patients were compared to 46 patients with unresectable cancer without distant metastases or peritoneal carcinomatosis, in which a bypass procedure was performed. Results Operating time and hospital stay were significantly longer after R2 resection. Intraoperative blood loss was significantly higher; and severe surgical complications and the need for relaparotomy were significantly more frequent after R2 resection. The 30-day mortality rate was higher after R2 resection; this difference was not statistically significant. Median survival was comparable in both groups. Two years after surgery, 22.6% of the patients after R2 resection were still alive compared to 10.9% after bypass surgery. Conclusion Tumor debulking is not a treatment option in patients with advanced pancreatic cancer, but the patient is not at a disadvantage compared to bypass procedures if tumor tissue remains and R0 resection cannot be achieved after surgical exploration. Keywords Pancreatic cancer . Pancreatic surgery . R2 resection Introduction Pancreatic cancer is the 4th to 5th most common reason for cancer-associated death in the Western world, with rising incidence and a still dismal prognosis [1]. Median survival time without therapy is 3–4 months after diagnosis, and only 20% of all patients with pancreatic cancer survive for more than one year [2]. Survival after surgery is also disappointing, with 5-year survival rates ranging from 10– 29% [3]. Pancreatic cancer has the worst prognosis and highest lethality among all gastrointestinal tumors. Unfor- tunately, at the time of diagnosis, around 85% of the patients are unsuitable for curative resection and are potential candidates for palliative treatment [4, 5]. One of the central difficulties in the treatment of pancreatic cancer is how to decide whether a tumor is resectable. Despite impressive advances in imaging tech- niques, surgical exploration remains the only approach to determine the possibility of complete tumor resection. The crucial point is that the final decision regarding resectability can very often only be made during extensive surgical exploration [6, 7]. Pancreatic cancer is characterized by a strong desmo- plastic reaction [8]. Suspected infiltration of the mesenteric radix, portal vein and vessels of the celiac trunk is often due to inflammatory side reactions, and appraisal is only possible after meticulous dissection of these regions [9, Langenbecks Arch Surg (2008) 393:929–934 DOI 10.1007/s00423-008-0308-4 J. Köninger : M. N. Wente : B. P. Müller-Stich : F. F. di Mola : C. N. Gutt : U. Hinz : M. W. Büchler (*) Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany e-mail: markus.buechler@med.uni-heidelberg.de Present address: M. W. Müller : H. Friess Department of Surgery, Technische Universität, Munich, Germany