Adenocarcinoma of the pancreas is the most difficult to treat, and the prognosis, even if curative resection is possible, is dismal. Improving survival in this intractable disease is a challenging issue. Most Japanese surgeons have stressed that resection with extended lymphadenectomy and autonomic nerve dissection (extended surgery) can offer a better chance of long-term survival. On the other hand, surgeons in Western countries are skeptical about extended surgery and have preferred resection without extended lymphadenectomy (standard surgery). Two randomized controlled trials (RCTs) on "standard vs. extended surgery for pancreatic head adenocarcinoma" were reported in 1998 from Italy and in 2002 from USA. Those two RCTs demonstrated that extended surgery did not improve patient survival; however, they had little impact on Japanese surgeons because the extended surgery used in those RCTs were not "true" extended surgery. Thereafter, one RCT was conducted in Japan in which extensive lymphadenectomy including paraaortic node and complete resection of autonomic nerves around the common hepatic and the superior mesenteric arteries were performed in extended surgery. Unexpectedly, the results showed that the survival rates were similar between extended and standard surgeries, compatible with the results of the Western RCTs. We should therefore conclude that extended surgery does not improve survival for patients with pancreas head adenocarcinoma.