Heterogeneity in the management of patients with locally advanced pancreatic cancer: current surgeons' perspective and lessons for the future.

The management of patients with locally advanced pancreatic cancer (LAPC) in the era of promising neoadjuvant treatments and “conversion” surgery remains challenging. This survey sought to register the current practices and perspectives of recognized pancreatic surgeons and provide valuable insights for future research. An online survey consisting of 18 questions on real-life challenging clinical situations was conducted using Google Forms. Participants were asked about their approach in the management of a 60-year-old patient with LAPC after 8 weeks of neoadjuvant chemotherapy in different settings of response to the neoadjuvant treatments and of intraoperative findings. Seventy-three respondents from 19 different countries completed the survey. 74% (54/73) of the respondents declared working at centers performing more than 50 pancreatic resections per year. Overall, the answers among participants were very heterogeneous. There was no consensus regarding the optimal duration of neoadjuvant chemotherapy, nor on the appropriate timing and indications for regimen modification. Similarly, the criteria for surgical exploration, the intraoperative strategies in case of venous or arterial involvement, and the role of perivascular frozen-section analysis in guiding intraoperative decisions remained debated among the participating surgeons. Here, the lack of knowledge in the current literature on these issues and the subsequent reliance on individual expertise may account for this heterogeneity. Further research efforts are required to address existing knowledge gaps and to advance and standardize the management of patients with LAPC.