In an older dialysis‑dependent patient with resectable pancreatic head adenocarcinoma, ECOG ≤2 and pre‑operative biliary stenting, which lymph‑node stations comprise the standard (classic) lymphadenectomy during a pancreaticoduodenectomy (Whipple)?

Standard Lymphadenectomy Stations in Whipple Surgery

Standard lymphadenectomy during pancreaticoduodenectomy should include removal of at least 16 lymph nodes from the following stations: hepatoduodenal ligament nodes, common hepatic artery nodes (station 8a), portal vein nodes, nodes along the bile duct (station 12b) and cystic duct (station 12c), posterior and inferior pancreatic head nodes (station 13a), right lateral side of the superior mesenteric artery (stations 14a and 14b), and anterior surface nodes of the superior and inferior pancreatic head (stations 17a and 17b). 1, 2

Specific Nodal Stations for Standard Lymphadenectomy

The following stations comprise the standard (classic) lymphadenectomy:

• Suprapyloric (station 5) and infrapyloric (station 6) nodes along the gastroduodenal region 2
• Common hepatic artery nodes (station 8a) along the hepatic artery proper 1, 2
• Bile duct nodes (station 12b) and cystic duct nodes (station 12c) within the hepatoduodenal ligament 2
• Posterior and inferior pancreatic head nodes (station 13a) 2
• Right lateral superior mesenteric artery nodes (stations 14a and 14b) – this represents the right half of the SMA nodal basin 1, 2
• Anterior surface nodes of the superior and inferior pancreatic head (stations 17a and 17b) 2
• Portal vein nodes along the course of the portal vein 1
• Right-sided celiac artery nodes 1

Minimum Nodal Yield Requirement

• At least 16 lymph nodes must be removed and examined to allow adequate pathological staging of pancreatic adenocarcinoma 1
• The total number of lymph nodes examined and the lymph node ratio (number of involved nodes divided by total nodes examined) should be reported in the pathological analysis 1

What is NOT Included in Standard Lymphadenectomy

• Extended lymphadenectomy is NOT recommended as a routine part of the Whipple procedure 1, 2, 3
• Extended resections involving block dissection of lymphatic tissue around the origins of the celiac and superior mesenteric arteries do not increase survival when carried out routinely 1
• Multiple randomized controlled trials have demonstrated no survival advantage with extended lymphadenectomy 2, 3

Technical Considerations for Optimal Nodal Harvest

• Complete mobilization of the portal vein and superior mesenteric vein from the uncinate process is essential for proper medial dissection and adequate nodal retrieval 2, 3
• Skeletonization of the superior mesenteric artery down to the adventitia along its lateral, posterior, and anterior borders maximizes uncinate tissue yield and improves nodal harvest from the right SMA stations 2, 3
• Dissection to the right of the celiac trunk is recommended to obtain optimal medial clearance 2

Special Considerations for Your Patient

In your dialysis-dependent patient with ECOG ≤2 and pre-operative biliary stenting:

• The plastic stent should remain in situ until surgery; it should not be removed or exchanged for a metal stent 1, 4
• Self-expanding metal stents should be avoided in patients proceeding to resection because they complicate surgical dissection 1, 4
• Surgery should be performed at a high-volume specialist center to minimize morbidity and mortality, particularly given the patient's dialysis dependence 1, 3
• The patient's renal function and performance status make careful patient selection critical, but age alone (even >75 years) is not a contraindication if comorbidities are acceptable 4, 5

Pathological Reporting Requirements

• Seven distinct margins must be identified and assessed: anterior, posterior, medial/superior mesenteric groove, superior mesenteric artery, pancreatic transection, bile duct, and enteric 2, 3
• Tumor clearance should be reported in millimeters for all margins 1, 2, 3
• The goal is R0 resection (no tumor cells within 1 mm of any resection margin), as this is the only independent prognostic factor for improved survival 2, 3, 6, 7