The potential for curative surgery depends on the staging of the tumour, and only 10–20 per cent of patients have clearly resectable disease after careful pretherapeutic staging. This potential is assessed by the multidisciplinary team.

Patients who undergo surgical resection for localised pancreatic cancer have a median survival of 15–20 months and a five-year survival of 8–15 per cent (Lambert et al. 2019). Unfortunately, 80 per cent of patients present with metastatic or locally advanced disease, by which time the tumour is unresectable (Lambert et al. 2019).

Unresectable tumours are defined based on the presence of metastases including non-regional lymph node involvement, more than 180 degrees of contact with the major vessels, or tumoural invasion of the major vessels (Elbanna et al. 2020).

Curative surgery includes the following options with or without chemotherapy (adjuvant or neoadjuvant chemotherapy or neoadjuvant chemoradiation):

• Whipple procedure (pancreaticoduodenal resection)
• distal pancreatectomy
• total pancreatectomy.

Timeframe for starting treatment

Surgery should be undertaken within four weeks of the initial diagnosis, depending on urgency and modality.

Training and experience required of the surgeon

Surgeon (FRACS or equivalent) with adequate training and experience in hepatobiliary surgery with institutional credentialing and agreed scope of practice within this area.

There is strong evidence to suggest that surgeons who undertake a high volume of resections have better clinical outcomes for complex cancer surgery such as pancreatic resections (Toomey et al. 2016).

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with pancreatic cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• diagnostic imaging
• endoscopic retrograde cholangiopancreatography (ERCP)
• 24-hour access to interventional radiology
• access to endoscopic ultrasound
• nuclear medicine imaging
• pathology
• full support from other surgical specialties.

There is strong evidence to suggest that high-volume hospitals have better clinical outcomes for complex cancer surgery such as pancreatic resections (Hata et al. 2016). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to high-volume centres.