In an older patient with resectable pancreatic head cancer whose renal function has been improved by intermittent hemodialysis and whose biliary obstruction has been relieved by ERCP stenting, should we proceed to pancreaticoduodenectomy now?

Proceed to Pancreaticoduodenectomy After Optimization

In an older patient with resectable pancreatic head cancer whose renal function has been restored with dialysis and biliary obstruction relieved by ERCP stenting, you should proceed to pancreaticoduodenectomy if the patient has acceptable performance status (ECOG ≤2) and the tumor remains resectable on restaging imaging. 1, 2

Critical Pre-Surgical Assessment

Performance Status Determines Candidacy

• Age alone is not a contraindication to resection in experienced centers, but severe comorbidities (ECOG PS >2) or severe malnutrition despite optimal supportive care may justify avoiding surgery even when technically feasible 1, 2
• The surgical outcomes pancreatectomy score, calculated from preoperative factors, accurately predicts perioperative mortality risk and should guide decision-making 1
• Chronological age (even >75-80 years) is not an absolute contraindication if comorbidity status is acceptable 1, 2

Renal Function Considerations

• Ensure the patient is dialysis-independent or has stable renal function before proceeding, as ongoing dialysis requirement significantly increases perioperative morbidity and mortality
• Verify that creatinine improvement is sustained and not just a temporary response to dialysis

Biliary Decompression Status

• The ERCP stent should remain in place until surgery - do not remove it preoperatively 1
• If a plastic stent was placed (appropriate choice for resectable disease), this is acceptable and should not be replaced with a metal stent 1
• Self-expanding metal stents should NOT be inserted in patients proceeding to resection, as they complicate the surgical dissection 1

Timing of Surgery After Biliary Drainage

Proceed Without Delay

• Surgery should proceed as soon as the patient is medically optimized - there is no benefit to prolonged waiting after biliary decompression 1
• A randomized trial demonstrated that routine preoperative biliary drainage actually increases complication rates in patients with bilirubin <250 μmol/L (146 mg/L) 1
• The indication for preoperative drainage was met (surgery delayed >2 weeks for medical optimization), but now that drainage is achieved, proceed expeditiously 1

Restaging Before Surgery

• Obtain repeat CT imaging to confirm the tumor remains resectable after the period of medical optimization 1
• Verify no interval development of metastatic disease or vascular involvement that would preclude R0 resection 1

Surgical Approach

Standard Pancreaticoduodenectomy

• Pancreaticoduodenectomy (with or without pylorus preservation) is the appropriate resectional procedure for pancreatic head tumors 1, 2
• The goal is R0 resection (no cancer cells within 1 mm of all resection margins) 1, 2
• Standard lymphadenectomy should involve removal of ≥16 nodes including hepatoduodenal ligament, common hepatic artery, portal vein, right-sided celiac artery, and right half of superior mesenteric artery nodes 1, 2

Operative Considerations After ERCP

• ERCP stenting is associated with easier dissection, less blood loss, shorter operative time, less postoperative bile leak, and shorter hospital stay compared to percutaneous drainage 3
• The presence of a plastic biliary stent should not significantly complicate the surgical dissection 3

Common Pitfalls to Avoid

Do Not Delay Surgery Unnecessarily

• Avoid prolonged waiting after biliary decompression is achieved, as this increases risk of stent occlusion, cholangitis, and disease progression 1, 4, 5
• The window of resectability may close if surgery is delayed 4, 5

Do Not Pursue Percutaneous Drainage

• Percutaneous transhepatic biliary drainage (PTBD) is associated with more difficult dissections, increased blood loss, longer operative times, higher hepatic recurrence rates, and worse overall survival compared to endoscopic drainage 3, 6
• PTBD patients have significantly worse median survival (17.5 months) compared to ERCP patients (22.4 months) or no drainage patients (28.9 months) 6

Do Not Withhold Surgery Based on Age Alone

• Elderly patients benefit from radical surgery when comorbidity status is acceptable 1, 2, 7
• A comprehensive systematic review concluded that chronological age is not a contraindication for resection in experienced centers 1

Expected Outcomes and Adjuvant Therapy

Survival Expectations

• R0 resection followed by 6 months of adjuvant chemotherapy (gemcitabine or 5-FU) provides 5-year survival of approximately 20%, compared to 9% without adjuvant therapy 2, 8
• This represents the only curative approach for pancreatic head cancer 2

Mandatory Adjuvant Chemotherapy

• All patients who undergo resection should receive 6 months of adjuvant chemotherapy with either gemcitabine or 5-FU 2, 8
• Adjuvant chemotherapy benefits patients even after R1 resection (positive margins) 2, 8
• Do not use adjuvant chemoradiation outside clinical trials, as there is no proven advantage over chemotherapy alone 8