In an older patient with resectable pancreatic head adenocarcinoma, dialysis‑dependent renal function stabilized, biliary obstruction relieved by ERCP (endoscopic retrograde cholangiopancreatography) stenting, and ECOG (Eastern Cooperative Oncology Group) performance status ≤2, what are the essential technical steps to achieve an R0 pancreaticoduodenectomy (Whipple)?

Essential Technical Steps for R0 Pancreaticoduodenectomy (Whipple Procedure)

The primary goal of pancreaticoduodenectomy is achieving an R0 resection (tumor clearance ≥1 mm from all margins) through meticulous perivascular dissection, complete mobilization of the portal and superior mesenteric veins from the uncinate process, and skeletonization of the superior mesenteric artery down to the adventitia. 1, 2

Critical Preoperative Considerations

Patient Selection and Staging:

• Only patients with a high probability of R0 resection based on radiological evaluation should proceed to upfront surgery 1
• Resectability is determined by vessel involvement: tumors are resectable when there is <180° contact with the superior mesenteric artery (SMA), celiac axis, or common hepatic artery without deformation 1
• For venous structures (portal vein/superior mesenteric vein), resectable tumors show no occlusion or distortion 1
• In this dialysis-dependent patient with ECOG ≤2, consultation at a high-volume center is strongly preferred given the technical complexity and comorbidities 1, 3

Biliary Management:

• Since biliary obstruction has already been relieved by ERCP stenting, this patient is appropriately prepared 2
• Short, self-expanding metal stents are preferred for preoperative biliary decompression due to minimal interference with subsequent resection 2

Essential Intraoperative Technical Steps

1. Medial Dissection and Uncinate Process Management

The most critical oncologic step is complete mobilization of the portal vein (PV) and superior mesenteric vein (SMV) from the uncinate process, assuming no evidence of tumor infiltration. 1, 2

• Skeletonization of the lateral, posterior, and anterior borders of the SMA down to the level of the adventitia maximizes uncinate yield and radial margin clearance 1, 2
• This dissection to the right of the celiac trunk is recommended to obtain good medial clearance and improve R0 resection rates 1
• Common pitfall: Inadequate dissection of the uncinate process leads to positive margins and decreased survival 2

2. Vascular Assessment and Management

Venous Resection:

• The need for lateral venorrhaphy or complete PV/SMV resection often becomes apparent only after division of the pancreatic neck 1, 2
• If tumor tethering to the lateral wall of the PV is encountered, careful dissection should attempt to free the vein 1
• When tumor infiltration is suspected (even if differentiation from desmoplasia is impossible), an aggressive approach with partial or complete vein excision and reconstruction should be performed to achieve R0 resection 1, 2
• PV or SMV resection is associated with lower R0 rates and poorer survival due to inherent tumor aggressiveness, but should not be avoided when necessary 1

Arterial Considerations:

• Arterial resections during pancreaticoduodenectomy are associated with increased morbidity and mortality and are not recommended 1
• Judicious arterial resection may be reasonable only in very select populations, though additional data are needed 1, 2

3. Margin Assessment and Lymphadenectomy

Seven Critical Margins Must Be Identified and Assessed: The International Study Group of Pancreatic Surgery recommends identifying: anterior, posterior, medial (superior mesenteric groove), SMA, pancreatic transection, bile duct, and enteric margins 1, 2, 3

• Frozen section analysis of pancreatic neck transection and common bile duct transection margins is recommended 1
• Tumor clearance should be reported in millimeters for all seven margins 1, 2
• R1 definition follows British Royal College of Pathologists guidelines: margin <1 mm 1

Standard Lymphadenectomy (Extended Lymphadenectomy NOT Recommended): For pancreaticoduodenectomy, standard lymphadenectomy should include 1:

• Suprapyloric (station 5) and infrapyloric (station 6) nodes
• Anteriosuperior group along common hepatic artery (station 8a)
• Nodes along bile duct (station 12b) and around cystic duct (station 12c)
• Posterior and inferior aspects of pancreatic head (station 13a)
• Right lateral side of SMA (stations 14a and 14b)
• Anterior surface of superior and inferior portions of pancreatic head (stations 17a and 17b)

Extended lymphadenectomy is not recommended as it does not improve survival 1, 2

Special Considerations for This High-Risk Patient

Dialysis-Dependent Renal Function:

• Close perioperative fluid management is critical to avoid volume overload 3
• Coordinate timing of dialysis with surgical and anesthesia teams
• Enhanced Recovery After Surgery (ERAS) protocols recommend maintaining fluid balance close to zero 3

Performance Status and Nutritional Optimization:

• Aggressive nutritional management both pre- and postoperatively optimizes oncological outcomes 3
• Early oral feeding is feasible and safe after Whipple procedures 3
• Artificial nutrition should be considered selectively only for prolonged delayed gastric emptying 3

Technical Approach Options

Open vs. Minimally Invasive:

• Open surgery remains the standard of care 1
• While minimally invasive techniques (laparoscopic or robotic) may reduce morbidity without negative impact on cancer outcomes, data relating to oncological results remain insufficient 1, 4
• Given this patient's complex comorbidities (dialysis-dependent), open approach is preferred for optimal oncologic control

Pylorus Preservation:

• Pylorus-preserving pancreaticoduodenectomy is the preferred technique when appropriate 3
• Standard Whipple involves dividing the stomach at the pylorus or distal stomach 2

Critical Pitfalls to Avoid

1. Inadequate uncinate dissection: Failure to completely mobilize the SMV/PV from the uncinate process compromises medial margins 2
2. Insufficient SMA skeletonization: Not dissecting down to the adventitia leaves residual tumor 1, 2
3. Hesitation with venous resection: When infiltration is suspected intraoperatively, failure to perform vein resection results in R1 resection 1, 2
4. Extended lymphadenectomy: This increases morbidity without survival benefit 1, 2
5. Failure to assess all seven margins: Incomplete pathologic assessment compromises accurate staging 1, 2