The DeBakey Triad: A Technical Innovation Integrating the Triangle Operation, Type III SMV–PV Resection, and ERAS in Pancreatic Head Cancer

The DeBakey Triad: A Technical Innovation Integrating the Triangle Operation, Type III SMV–PV Resection, and ERAS in Pancreatic Head Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Data Note The DeBakey Triad: A Technical Innovation Integrating the Triangle Operation, Type III SMV–PV Resection, and ERAS in Pancreatic Head Cancer Yasser Debakey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8239084/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Borderline-resectable pancreatic head cancer with venous involvement demands an operative strategy that balances oncologic radicality, vascular precision, and postoperative recovery. We describe the DeBakey Triad, a unified technical framework integrating the Triangle Operation, Type III SMV–PV segmental venous resection, and Enhanced Recovery After Surgery (ERAS) principles. Technique Summary The DeBakey Triad consists of three interdependent elements performed in deliberate sequence: Radical mesopancreatic excision (Triangle Operation) to expose the SMA, celiac axis, and SMV–PV confluence. Type III venous resection targeting the fixed post-neoadjuvant tumor–vessel interface, followed by primary SMV–PV end-to-end reconstruction. Structured ERAS integration to support early physiological recovery and reduce postoperative morbidity. This sequence standardizes both technical execution and perioperative workflow for anatomically complex pancreatic head cancers. Illustrative Application We demonstrate the technique using a post-neoadjuvant borderline-resectable case involving SMV–PV confluence involvement. The DeBakey Triad enabled an R0 resection, secure venous reconstruction, preserved postoperative venous patency, and safe discharge in < 100 hours. Conclusion The DeBakey Triad represents an operative innovation that unifies radical dissection, formal venous resection, and enhanced recovery into a cohesive framework. This approach provides clarity, reproducibility, and physiologic advantage in the management of borderline-resectable pancreatic head cancer. Surgery Triangle Operation DeBakey Triad Pancreaticoduodenectomy Venous Resection SMV–PV Reconstruction Borderline-Resectable Pancreatic Cancer ERAS Technical Innovation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION Borderline-resectable pancreatic ductal adenocarcinoma (PDAC) involving the superior mesenteric vein–portal vein (SMV–PV) confluence remains one of the most technically demanding scenarios in pancreatic surgery. Even after modern neoadjuvant therapy, persistent tumor–vessel interfaces and dense post-treatment fibrosis frequently limit the effectiveness of standard pancreaticoduodenectomy, and inadequate clearance of the retroperitoneal fibro-neural tissue contributes to high circumferential margin positivity ( 1 – 3 ). The Triangle Operation was introduced to address these limitations by establishing a reproducible framework for radical mesopancreatic excision. Its emphasis on systematic lympho-neural clearance and skeletonization of the SMA, celiac axis, and SMV–PV confluence enhances exposure of the posterior and medial planes and improves the reliability of R0 resection, particularly in the post-neoadjuvant setting where tissue planes are obscured ( 4 ). Venous involvement at the SMV–PV confluence is a defining feature of borderline-resectable PDAC. International consensus guidelines support venous resection when arterial structures are uninvolved ( 5 ), and systematic reviews confirm that segmental SMV–PV resection can be performed safely with oncologic outcomes comparable to standard pancreaticoduodenectomy in selected patients ( 6 , 7 ). Neoadjuvant therapy—most notably FOLFIRINOX—has improved the biological and technical feasibility of resection in borderline-resectable disease ( 8 – 10 ). However, neoadjuvant-induced fibrosis frequently necessitates deliberate venous resection rather than preservation attempts. This reinforces the need for a structured operative sequence integrating radical dissection with vascular precision. Enhanced Recovery After Surgery (ERAS) pathways further reduce complications and shorten hospital stay after pancreaticoduodenectomy ( 11 – 13 ). When the operative technique minimizes tissue trauma, blood loss, and fluid imbalance, ERAS protocols achieve maximal effect. Thus, perioperative recovery should be embedded within the operative design—not applied as a postoperative adjunct. To unify these complementary but traditionally separate elements, we propose the DeBakey Triad—a three-component operative strategy integrating: Radical mesopancreatic excision via the Triangle Operation ( 4 ) Type III SMV–PV venous resection with primary reconstruction ( 6 , 7 ) ERAS-driven physiological optimization ( 11 – 13 ) This Technical Note describes the structure, rationale, and operative sequence of the DeBakey Triad and demonstrates its application in a post-neoadjuvant borderline-resectable pancreatic head cancer. TECHNICAL DESCRIPTION 4.1 Rationale and Operative Sequencing The DeBakey Triad is designed as a sequential, interdependent operative framework that addresses the three principal challenges of borderline-resectable pancreatic head cancer after neoadjuvant therapy: ( 1 ) radical mesopancreatic clearance, ( 2 ) anatomically precise venous resection, and ( 3 ) optimized physiological recovery. Neoadjuvant therapy frequently results in dense fibrosis along the SMV–PV confluence ( 8 – 10 ), making preservation attempts unsafe and risking margin compromise. A structured operative sequence ensures safe vascular control, reliable dissection planes, and alignment with ERAS principles ( 11 – 13 ). 4.2 Triangle Operation Component The procedure begins with wide kocherization and full posterior mobilization of the duodenum and pancreatic head. The Triangle Operation, as described by Hirai et al. ( 4 ), involves systematic mesopancreatic excision and skeletonization of the SMA, celiac axis, and SMV–PV confluence. The goals are: Radical exposure of the medial and posterior planes Clearance of fibro-neural tissue associated with local recurrence ( 2 , 3 ) Optimization of vascular control for subsequent venous resection Identification of the precise post-neoadjuvant tumor–vessel interface ( 8 – 10 ) This dissection enhances oncologic reliability and facilitates safe vascular intervention. Figure 2 A demonstrates the completed Triangle Operation field with full exposure of the SMA, SMV–PV confluence, celiac axis, and hepatic artery. 4.3 Type III Venous Resection Component Persistent post-neoadjuvant tumor–vessel interface at the SMV–PV confluence represents a recognized indication for formal venous resection ( 5 – 7 ). Once the Triangle Operation is completed, the vascular anatomy is fully displayed, enabling safe proximal and distal control. The venous segment targeted for resection corresponds to the true zone of fixation, typically the area immediately distal to the splenic vein insertion, where post-treatment fibrosis is most pronounced ( 6 , 7 ). This location also allows for a tension-free reconstruction. Clamping is performed only after all peripancreatic attachments are released and the retropancreatic tunnel is cleared. The involved segment is excised en bloc. Figure 2 B shows the venotomy edges and vascular control following segmental resection, representing the venous phase of the DeBakey Triad. The choice of a Type III resection is based on: A short venous involvement segment (< 2 cm) Absence of arterial encasement ( 5 ) Favorable conditions for primary anastomosis Fibrotic post-neoadjuvant changes requiring excision rather than peeling ( 8 – 10 ) 4.4 Venous Reconstruction Component Reconstruction is performed with primary end-to-end anastomosis using fine polypropylene sutures. Standardized principles derived from validated vascular techniques ( 6 , 7 ) include: Careful geometric alignment of luminal edges Avoidance of tension by mobilizing both SMV and PV Continuous running sutures for uniform approximation Hemostatic confirmation and patency verification following declamping This technique avoids graft-related morbidity and preserves physiologic venous flow. 4.5 Reconstruction of Digestive Continuity Digestive reconstruction proceeds with: A modified Blumgart pancreaticojejunostomy (duct-to-mucosa with U-sutures), A single-layer hepaticojejunostomy, An antecolic gastrojejunostomy. This approach minimizes the risk of POPF and preserves early functional recovery, both critical components for ERAS success ( 11 – 13 ). 4.6 Integration of ERAS Principles The final component of the DeBakey Triad embeds ERAS principles directly into operative planning. Early recovery is enabled by: Atraumatic radical dissection minimizing inflammatory burden Meticulous vascular technique reducing blood loss and fluid shifts Early enteral nutrition supported by safe reconstruction Early mobilization facilitated by stable hemodynamics ERAS has been shown to reduce complications and shorten length of stay following pancreaticoduodenectomy ( 11 – 13 ). In this framework, ERAS is not an adjunct—it is structurally integrated into the operative philosophy. In the illustrative case, these principles enabled a safe discharge in less than 100 hours, aligning with contemporary ERAS benchmarks. ILLUSTRATIVE CASE A 53-year-old male with pancreatic head and uncinate ductal adenocarcinoma underwent neoadjuvant FOLFIRINOX with biochemical response but persistent tumor–vessel interface on restaging imaging, consistent with borderline-resectable disease by consensus definitions ( 5 , 8 , 9 ). Coronal post-treatment CT (Fig. 1 A) demonstrated an ongoing tumor–SMV interface, while axial venous-phase imaging (Fig. 1 B) confirmed persistent SMV involvement at the confluence, a pattern frequently attributed to post-treatment fibrosis rather than simple inflammatory adherence ( 8 – 10 ). The DeBakey Triad was applied in sequential fashion: Triangle Operation was performed to achieve radical mesopancreatic clearance, exposing the SMA, celiac axis, and SMV–PV confluence (Fig. 2 A) as recommended for optimal retroperitoneal margin clearance ( 1 – 4 ). A Type III SMV–PV segmental resection—targeting the short, fixed interface immediately distal to the splenic vein insertion—was completed with safe proximal and distal control (Fig. 2 B), in accordance with established criteria for venous resection in borderline-resectable PDAC ( 5 – 7 ). Primary end-to-end reconstruction restored vascular continuity (Fig. 2 C), consistent with established techniques shown to provide safe patency and favorable outcomes ( 6 , 7 ). The postoperative course followed a structured ERAS pathway, which has been shown to reduce morbidity and accelerate recovery after pancreaticoduodenectomy ( 11 – 13 ). Early postoperative imaging demonstrated preserved flow across the reconstructed venous segment (Figs. 3 A and 3 B). The patient achieved safe discharge in less than 100 hours, reflecting the synergy between meticulous technique and ERAS-driven recovery. Final pathology confirmed R0 resection with complete removal of the involved venous segment. DISCUSSION Borderline-resectable pancreatic head cancer continues to present a formidable operative challenge due to its proximity to the SMA and SMV–PV confluence and the high prevalence of retroperitoneal circumferential margin involvement ( 1 – 3 ). Neoadjuvant therapy improves biological and technical resectability, yet post-treatment fibrosis frequently obscures tissue planes and intensifies the adhesion between the pancreatic head/uncinate process and the venous confluence ( 8 – 10 ). As a result, attempts to preserve the vein may jeopardize the R0 margin, underscoring the importance of deliberate venous resection within a structured operative strategy. The Triangle Operation addresses the oncologic limitations of traditional pancreaticoduodenectomy by defining reproducible anatomic boundaries for radical mesopancreatic excision. Its emphasis on systematic lympho-neural clearance and complete exposure of the SMA, celiac axis, and SMV–PV confluence improves margin status and enhances operative safety, particularly after neoadjuvant therapy when soft tissue planes are poorly defined ( 4 ). This radical exposure provides the anatomic clarity required for safe vascular control and sets the foundation for precise venous resection. Segmental SMV–PV resection has been validated as an essential component of borderline-resectable PDAC management ( 5 – 7 ). Meta-analyses and multicenter series demonstrate that venous resection can be performed with acceptable morbidity and comparable survival outcomes when arterial involvement is absent and reconstruction is technically feasible ( 6 , 7 ). In the post-neoadjuvant setting, persistent venous contact often reflects fibrosis rather than true tumor encasement, yet this distinction does not eliminate the need for resection—since fibrosis itself may harbor residual microscopic disease ( 8 – 10 ). The DeBakey Triad explicitly integrates the Triangle Operation with Type III venous resection, ensuring that the vascular component is executed only after full exposure and complete dissection of the mesopancreatic planes. The reconstructive phase of the triad relies on primary end-to-end anastomosis, a technique associated with lower thrombosis rates and fewer complications relative to graft use when the resected segment is short and tension-free approximation is achievable ( 6 , 7 ). The anatomic position of the resected segment—immediately distal to the splenic vein insertion—provides a reliable and reproducible location for surgeons performing segmental venous resection in the context of borderline-resectable disease. A key innovative aspect of the DeBakey Triad is the deliberate incorporation of ERAS principles into the technical design rather than viewing ERAS as a postoperative adjunct. Evidence consistently demonstrates that ERAS protocols reduce morbidity, improve functional recovery, and shorten hospital stay after pancreaticoduodenectomy ( 11 – 13 ). The triad’s emphasis on atraumatic dissection, meticulous hemostasis, reduced fluid shifts, and simplified reconstruction directly supports early mobilization, early feeding, and early discharge. In the illustrative case, this synergy enabled safe discharge in under 100 hours, a meaningful benchmark even in high-volume centers. While this Technical Note presents a single illustrative application, the DeBakey Triad itself is a conceptual and technical framework applicable across a broad range of anatomically complex, post-neoadjuvant pancreatic cancers. Future prospective evaluation and multi-institutional adoption may further refine its operative indications, validate its reproducibility, and clarify its role in modern HPB oncology. CONCLUSION The DeBakey Triad provides a coherent operative framework for managing borderline-resectable pancreatic head cancer after neoadjuvant therapy. By integrating radical mesopancreatic excision through the Triangle Operation, anatomically precise Type III SMV–PV resection with primary reconstruction, and ERAS-driven physiological optimization, the triad unifies oncologic radicality, vascular precision, and enhanced recovery into a single structured sequence. This approach enhances anatomic clarity, standardizes venous resection, and facilitates rapid and safe postoperative recovery—even in technically demanding post-treatment fields. While the present illustration demonstrates its feasibility, broader clinical application and prospective evaluation may further define its impact and establish its role within contemporary HPB surgical practice. Declarations Ethical Approval This work involved the reporting of a single surgical case and technical innovation. All procedures were performed in accordance with institutional guidelines and the ethical standards of the National Cancer Institute, Cairo University. Ethical approval for publication of anonymized clinical data and imaging was obtained under institutional review provisions. Informed Consent Written informed consent was obtained from the patient for the surgical procedure, for the use of clinical data, and for publication of anonymized operative photographs and radiologic images. All identifying information has been removed to protect patient confidentiality. Conflict of Interest The author declares no conflicts of interest related to this work. Funding This research and manuscript preparation received no external funding. All operative work and postoperative management were conducted as part of routine clinical care at the National Cancer Institute of Cairo University and affiliated hospitals. Author Contributions Yasser Eldebakey, MD: Conceptualization of the DeBakey Triad Development of the operative technique Surgical performance of all operative steps Acquisition of intraoperative and postoperative images Drafting, editing, and critical revision of the manuscript Approval of the final version for submission No other authors contributed to this Technical Note. Data Availability All data related to this work, including operative images and postoperative imaging, are included within the manuscript as figures. Additional anonymized information is available from the corresponding author upon reasonable request. References Isaji S, Murata Y, Kishiwada M et al (2018) New Japanese classification of pancreatic cancer: From the concept of locally advanced to borderline resectable pancreatic cancer. J Hepatobiliary Pancreat Sci 25(7):342–352 Delpero JR, Bachellier P (2017) Mesopancreas and circumferential margin in pancreatic head cancer. Pancreatic Cancer. 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Ann Surg 277(1):e129–e138 Conroy T, Desseigne F, Ychou M et al (2011) FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 364:1817–1825 Sohal DPS, Duong M, Ahmad SA et al (2019) Neoadjuvant therapy for pancreatic cancer: ASCO clinical practice guideline. J Clin Oncol 37(23):2082–2088 Springer S, Monteiro M, Jiao Y et al (2020) Circulating tumor DNA analysis in pancreatic cancer patients undergoing neoadjuvant therapy. Clin Cancer Res 26(10):2212–2220 Coolsen MME, van Dam RM, Choi WJ et al (2013) Enhanced Recovery After Surgery in pancreatic surgery: A systematic review. Ann Surg 257(6):929–936 Lee MK, Javed AA, Zheng L et al (2019) ERAS shortens recovery and reduces complications after pancreatoduodenectomy. J Gastrointest Surg 23(4):771–781 Braga M, Pecorelli N, Capretti G, Balzano G, Doglioni C, Gennari L (2012) Enhanced recovery after pancreatoduodenectomy: Pilot study in 100 consecutive patients. Med (Baltim) 91(3):e122–e130 Additional Declarations The authors declare no competing interests. Supplementary Files d393f837a25f44ab98038d42189dd5f4.jpeg d393f837a25f44ab98038d42189dd5f4.jpeg Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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2","display":"","copyAsset":false,"role":"figure","size":614811,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1B: Axial CT After Neoadjuvant Therapy Showing Ongoing SMV Encasement Interface by the Pancreatic Head Lesion.\u003c/p\u003e","description":"","filename":"IMG0078.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/3c9ead13636850575d288372.jpeg"},{"id":97367839,"identity":"3bd0ef3e-55fd-4771-8f32-79428620cc88","added_by":"auto","created_at":"2025-12-03 16:20:52","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":663442,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2A : Intraoperative definition of the Triangle Operation field, with complete dissection along the SMA and SMV–PV confluence and superior extension toward the celiac axis and hepatic artery to ensure radical posterior and medial margins.\u003c/p\u003e","description":"","filename":"IMG0079.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/058dbc52a3a5c3b3e3a0a763.jpeg"},{"id":97270846,"identity":"991699f9-41b3-40f5-8ba8-c3dffe4dcf37","added_by":"auto","created_at":"2025-12-02 14:58:25","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":227687,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2B: Intraoperative view of the venous phase of the DeBakey Triad, demonstrating a Type III SMV–PV resection with the venotomy edges exposed under vascular control prior to end-to-end reconstruction.\u003c/p\u003e","description":"","filename":"IMG0080.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/c0bc22d333eb124c8963658e.jpeg"},{"id":97270862,"identity":"fcefc5bf-02bf-4747-8baa-3abb69a0333b","added_by":"auto","created_at":"2025-12-02 14:58:25","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":383546,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2C: Completion phase of the venous component of the DeBakey Triad, showing the reconstructed SMV–PV segment following Type III resection, with restored continuity and hemostasis confirmed after clamp removal.\u003c/p\u003e","description":"","filename":"IMG0081.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/55eadbdd2e52a235cffac5be.jpeg"},{"id":97367481,"identity":"85f14e0c-9b2e-4cfe-a4d0-ab40fe19f130","added_by":"auto","created_at":"2025-12-03 16:18:55","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":259901,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3A.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAxial contrast-enhanced postoperative CT illustrating restored continuity and maintained flow within the reconstructed SMV–PV confluence following radical venous resection.\u003c/p\u003e","description":"","filename":"IMG0087.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/9e4ed47267ae91b0bf9a3b38.jpeg"},{"id":97270869,"identity":"804db929-aa7e-4ddb-b3b8-1cd45db6557b","added_by":"auto","created_at":"2025-12-02 14:58:25","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":305229,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3B.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCoronal postoperative CT illustrating restored continuity and maintained flow across the reconstructed SMV–PV segment, consistent with a successful venous phase of the DeBakey Triad.\u003c/p\u003e","description":"","filename":"IMG0088.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/504f440f502e9c8bddfcc6bd.jpeg"},{"id":97664558,"identity":"d1bb6c01-1c01-4edf-8ee4-ee2a7bcc10cb","added_by":"auto","created_at":"2025-12-08 09:10:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3544661,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/ae4af060-4e7c-4c20-9e1f-90a2a5252e33.pdf"},{"id":97270843,"identity":"7372a65b-1755-4869-9571-68cbff4612d9","added_by":"auto","created_at":"2025-12-02 14:58:25","extension":"jpeg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":408607,"visible":true,"origin":"","legend":"","description":"","filename":"d393f837a25f44ab98038d42189dd5f4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/fe6679ae2552f3d34c7b181b.jpeg"},{"id":97270853,"identity":"5c9efe6f-771d-42c4-a647-4e62e7cc8cf6","added_by":"auto","created_at":"2025-12-02 14:58:25","extension":"jpeg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":408607,"visible":true,"origin":"","legend":"","description":"","filename":"d393f837a25f44ab98038d42189dd5f4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8239084/v1/ef5fe6172ec69c21d49506c8.jpeg"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eThe DeBakey Triad: A Technical Innovation Integrating the Triangle Operation, Type III SMV–PV Resection, and ERAS in Pancreatic Head Cancer\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBorderline-resectable pancreatic ductal adenocarcinoma (PDAC) involving the superior mesenteric vein\u0026ndash;portal vein (SMV\u0026ndash;PV) confluence remains one of the most technically demanding scenarios in pancreatic surgery. Even after modern neoadjuvant therapy, persistent tumor\u0026ndash;vessel interfaces and dense post-treatment fibrosis frequently limit the effectiveness of standard pancreaticoduodenectomy, and inadequate clearance of the retroperitoneal fibro-neural tissue contributes to high circumferential margin positivity (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Triangle Operation was introduced to address these limitations by establishing a reproducible framework for radical mesopancreatic excision. Its emphasis on systematic lympho-neural clearance and skeletonization of the SMA, celiac axis, and SMV\u0026ndash;PV confluence enhances exposure of the posterior and medial planes and improves the reliability of R0 resection, particularly in the post-neoadjuvant setting where tissue planes are obscured (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVenous involvement at the SMV\u0026ndash;PV confluence is a defining feature of borderline-resectable PDAC. International consensus guidelines support venous resection when arterial structures are uninvolved (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and systematic reviews confirm that segmental SMV\u0026ndash;PV resection can be performed safely with oncologic outcomes comparable to standard pancreaticoduodenectomy in selected patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeoadjuvant therapy\u0026mdash;most notably FOLFIRINOX\u0026mdash;has improved the biological and technical feasibility of resection in borderline-resectable disease (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, neoadjuvant-induced fibrosis frequently necessitates deliberate venous resection rather than preservation attempts. This reinforces the need for a structured operative sequence integrating radical dissection with vascular precision.\u003c/p\u003e\u003cp\u003eEnhanced Recovery After Surgery (ERAS) pathways further reduce complications and shorten hospital stay after pancreaticoduodenectomy (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). When the operative technique minimizes tissue trauma, blood loss, and fluid imbalance, ERAS protocols achieve maximal effect. Thus, perioperative recovery should be embedded within the operative design\u0026mdash;not applied as a postoperative adjunct.\u003c/p\u003e\u003cp\u003eTo unify these complementary but traditionally separate elements, we propose the DeBakey Triad\u0026mdash;a three-component operative strategy integrating:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRadical mesopancreatic excision via the Triangle Operation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eType III SMV\u0026ndash;PV venous resection with primary reconstruction (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eERAS-driven physiological optimization (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis Technical Note describes the structure, rationale, and operative sequence of the DeBakey Triad and demonstrates its application in a post-neoadjuvant borderline-resectable pancreatic head cancer.\u003c/p\u003e"},{"header":"TECHNICAL DESCRIPTION","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Rationale and Operative Sequencing\u003c/h2\u003e\u003cp\u003eThe DeBakey Triad is designed as a sequential, interdependent operative framework that addresses the three principal challenges of borderline-resectable pancreatic head cancer after neoadjuvant therapy:\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) radical mesopancreatic clearance,\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) anatomically precise venous resection, and\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) optimized physiological recovery.\u003c/p\u003e\u003cp\u003eNeoadjuvant therapy frequently results in dense fibrosis along the SMV\u0026ndash;PV confluence (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), making preservation attempts unsafe and risking margin compromise. A structured operative sequence ensures safe vascular control, reliable dissection planes, and alignment with ERAS principles (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Triangle Operation Component\u003c/h2\u003e\u003cp\u003eThe procedure begins with wide kocherization and full posterior mobilization of the duodenum and pancreatic head. The Triangle Operation, as described by Hirai et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), involves systematic mesopancreatic excision and skeletonization of the SMA, celiac axis, and SMV\u0026ndash;PV confluence.\u003c/p\u003e\u003cp\u003eThe goals are:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eRadical exposure of the medial and posterior planes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eClearance of fibro-neural tissue associated with local recurrence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOptimization of vascular control for subsequent venous resection\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIdentification of the precise post-neoadjuvant tumor\u0026ndash;vessel interface (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis dissection enhances oncologic reliability and facilitates safe vascular intervention.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e2\u003c/span\u003eA demonstrates the completed Triangle Operation field with full exposure of the SMA, SMV\u0026ndash;PV confluence, celiac axis, and hepatic artery.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Type III Venous Resection Component\u003c/h2\u003e\u003cp\u003ePersistent post-neoadjuvant tumor\u0026ndash;vessel interface at the SMV\u0026ndash;PV confluence represents a recognized indication for formal venous resection (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Once the Triangle Operation is completed, the vascular anatomy is fully displayed, enabling safe proximal and distal control.\u003c/p\u003e\u003cp\u003eThe venous segment targeted for resection corresponds to the true zone of fixation, typically the area immediately distal to the splenic vein insertion, where post-treatment fibrosis is most pronounced (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis location also allows for a tension-free reconstruction.\u003c/p\u003e\u003cp\u003eClamping is performed only after all peripancreatic attachments are released and the retropancreatic tunnel is cleared. The involved segment is excised en bloc.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e2\u003c/span\u003eB shows the venotomy edges and vascular control following segmental resection, representing the venous phase of the DeBakey Triad.\u003c/p\u003e\u003cp\u003eThe choice of a Type III resection is based on:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA short venous involvement segment (\u0026lt;\u0026thinsp;2 cm)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAbsence of arterial encasement (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFavorable conditions for primary anastomosis\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFibrotic post-neoadjuvant changes requiring excision rather than peeling (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Venous Reconstruction Component\u003c/h2\u003e\u003cp\u003eReconstruction is performed with primary end-to-end anastomosis using fine polypropylene sutures. Standardized principles derived from validated vascular techniques (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) include:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCareful geometric alignment of luminal edges\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAvoidance of tension by mobilizing both SMV and PV\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eContinuous running sutures for uniform approximation\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHemostatic confirmation and patency verification following declamping\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis technique avoids graft-related morbidity and preserves physiologic venous flow.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Reconstruction of Digestive Continuity\u003c/h2\u003e\u003cp\u003eDigestive reconstruction proceeds with:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA modified Blumgart pancreaticojejunostomy (duct-to-mucosa with U-sutures),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA single-layer hepaticojejunostomy,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAn antecolic gastrojejunostomy.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis approach minimizes the risk of POPF and preserves early functional recovery, both critical components for ERAS success (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Integration of ERAS Principles\u003c/h2\u003e\u003cp\u003eThe final component of the DeBakey Triad embeds ERAS principles directly into operative planning. Early recovery is enabled by:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAtraumatic radical dissection minimizing inflammatory burden\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMeticulous vascular technique reducing blood loss and fluid shifts\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEarly enteral nutrition supported by safe reconstruction\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEarly mobilization facilitated by stable hemodynamics\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eERAS has been shown to reduce complications and shorten length of stay following pancreaticoduodenectomy (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this framework, ERAS is not an adjunct\u0026mdash;it is structurally integrated into the operative philosophy.\u003c/p\u003e\u003cp\u003eIn the illustrative case, these principles enabled a safe discharge in less than 100 hours, aligning with contemporary ERAS benchmarks.\u003c/p\u003e\u003c/div\u003e"},{"header":"ILLUSTRATIVE CASE","content":"\u003cp\u003eA 53-year-old male with pancreatic head and uncinate ductal adenocarcinoma underwent neoadjuvant FOLFIRINOX with biochemical response but persistent tumor\u0026ndash;vessel interface on restaging imaging, consistent with borderline-resectable disease by consensus definitions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Coronal post-treatment CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) demonstrated an ongoing tumor\u0026ndash;SMV interface, while axial venous-phase imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e1\u003c/span\u003eB) confirmed persistent SMV involvement at the confluence, a pattern frequently attributed to post-treatment fibrosis rather than simple inflammatory adherence (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe DeBakey Triad was applied in sequential fashion:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTriangle Operation was performed to achieve radical mesopancreatic clearance, exposing the SMA, celiac axis, and SMV\u0026ndash;PV confluence (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) as recommended for optimal retroperitoneal margin clearance (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eA Type III SMV\u0026ndash;PV segmental resection\u0026mdash;targeting the short, fixed interface immediately distal to the splenic vein insertion\u0026mdash;was completed with safe proximal and distal control (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e2\u003c/span\u003eB), in accordance with established criteria for venous resection in borderline-resectable PDAC (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePrimary end-to-end reconstruction restored vascular continuity (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), consistent with established techniques shown to provide safe patency and favorable outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe postoperative course followed a structured ERAS pathway, which has been shown to reduce morbidity and accelerate recovery after pancreaticoduodenectomy (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Early postoperative imaging demonstrated preserved flow across the reconstructed venous segment (Figs.\u0026nbsp;\u003cspan refid=\"Fig15\" class=\"InternalRef\"\u003e3\u003c/span\u003eA and \u003cspan refid=\"Fig15\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The patient achieved safe discharge in less than 100 hours, reflecting the synergy between meticulous technique and ERAS-driven recovery.\u003c/p\u003e\u003cp\u003eFinal pathology confirmed R0 resection with complete removal of the involved venous segment.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eBorderline-resectable pancreatic head cancer continues to present a formidable operative challenge due to its proximity to the SMA and SMV\u0026ndash;PV confluence and the high prevalence of retroperitoneal circumferential margin involvement (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Neoadjuvant therapy improves biological and technical resectability, yet post-treatment fibrosis frequently obscures tissue planes and intensifies the adhesion between the pancreatic head/uncinate process and the venous confluence (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). As a result, attempts to preserve the vein may jeopardize the R0 margin, underscoring the importance of deliberate venous resection within a structured operative strategy.\u003c/p\u003e\u003cp\u003eThe Triangle Operation addresses the oncologic limitations of traditional pancreaticoduodenectomy by defining reproducible anatomic boundaries for radical mesopancreatic excision. Its emphasis on systematic lympho-neural clearance and complete exposure of the SMA, celiac axis, and SMV\u0026ndash;PV confluence improves margin status and enhances operative safety, particularly after neoadjuvant therapy when soft tissue planes are poorly defined (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This radical exposure provides the anatomic clarity required for safe vascular control and sets the foundation for precise venous resection.\u003c/p\u003e\u003cp\u003eSegmental SMV\u0026ndash;PV resection has been validated as an essential component of borderline-resectable PDAC management (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Meta-analyses and multicenter series demonstrate that venous resection can be performed with acceptable morbidity and comparable survival outcomes when arterial involvement is absent and reconstruction is technically feasible (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the post-neoadjuvant setting, persistent venous contact often reflects fibrosis rather than true tumor encasement, yet this distinction does not eliminate the need for resection\u0026mdash;since fibrosis itself may harbor residual microscopic disease (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The DeBakey Triad explicitly integrates the Triangle Operation with Type III venous resection, ensuring that the vascular component is executed only after full exposure and complete dissection of the mesopancreatic planes.\u003c/p\u003e\u003cp\u003eThe reconstructive phase of the triad relies on primary end-to-end anastomosis, a technique associated with lower thrombosis rates and fewer complications relative to graft use when the resected segment is short and tension-free approximation is achievable (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The anatomic position of the resected segment\u0026mdash;immediately distal to the splenic vein insertion\u0026mdash;provides a reliable and reproducible location for surgeons performing segmental venous resection in the context of borderline-resectable disease.\u003c/p\u003e\u003cp\u003eA key innovative aspect of the DeBakey Triad is the deliberate incorporation of ERAS principles into the technical design rather than viewing ERAS as a postoperative adjunct. Evidence consistently demonstrates that ERAS protocols reduce morbidity, improve functional recovery, and shorten hospital stay after pancreaticoduodenectomy (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The triad\u0026rsquo;s emphasis on atraumatic dissection, meticulous hemostasis, reduced fluid shifts, and simplified reconstruction directly supports early mobilization, early feeding, and early discharge. In the illustrative case, this synergy enabled safe discharge in under 100 hours, a meaningful benchmark even in high-volume centers.\u003c/p\u003e\u003cp\u003eWhile this Technical Note presents a single illustrative application, the DeBakey Triad itself is a conceptual and technical framework applicable across a broad range of anatomically complex, post-neoadjuvant pancreatic cancers. Future prospective evaluation and multi-institutional adoption may further refine its operative indications, validate its reproducibility, and clarify its role in modern HPB oncology.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe DeBakey Triad provides a coherent operative framework for managing borderline-resectable pancreatic head cancer after neoadjuvant therapy. By integrating radical mesopancreatic excision through the Triangle Operation, anatomically precise Type III SMV\u0026ndash;PV resection with primary reconstruction, and ERAS-driven physiological optimization, the triad unifies oncologic radicality, vascular precision, and enhanced recovery into a single structured sequence.\u003c/p\u003e\u003cp\u003eThis approach enhances anatomic clarity, standardizes venous resection, and facilitates rapid and safe postoperative recovery\u0026mdash;even in technically demanding post-treatment fields. While the present illustration demonstrates its feasibility, broader clinical application and prospective evaluation may further define its impact and establish its role within contemporary HPB surgical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work involved the reporting of a single surgical case and technical innovation. All procedures were performed in accordance with institutional guidelines and the ethical standards of the National Cancer Institute, Cairo University. Ethical approval for publication of anonymized clinical data and imaging was obtained under institutional review provisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the surgical procedure, for the use of clinical data, and for publication of anonymized operative photographs and radiologic images. All identifying information has been removed to protect patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research and manuscript preparation received no external funding.\u003c/p\u003e\n\u003cp\u003eAll operative work and postoperative management were conducted as part of routine clinical care at the National Cancer Institute of Cairo University and affiliated hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYasser Eldebakey, MD:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eConceptualization of the DeBakey Triad\u003c/li\u003e\n \u003cli\u003eDevelopment of the operative technique\u003c/li\u003e\n \u003cli\u003eSurgical performance of all operative steps\u003c/li\u003e\n \u003cli\u003eAcquisition of intraoperative and postoperative images\u003c/li\u003e\n \u003cli\u003eDrafting, editing, and critical revision of the manuscript\u003c/li\u003e\n \u003cli\u003eApproval of the final version for submission\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo other authors contributed to this Technical Note.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data related to this work, including operative images and postoperative imaging, are included within the manuscript as figures. Additional anonymized information is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIsaji S, Murata Y, Kishiwada M et al (2018) New Japanese classification of pancreatic cancer: From the concept of locally advanced to borderline resectable pancreatic cancer. J Hepatobiliary Pancreat Sci 25(7):342\u0026ndash;352\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDelpero JR, Bachellier P (2017) Mesopancreas and circumferential margin in pancreatic head cancer. Pancreatic Cancer. Springer\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsposito I, Konukiewitz B, Schlitter AM, Kl\u0026ouml;ppel G (2014) Pathology of pancreatic ductal adenocarcinoma: Facts, challenges, and future developments. World J Gastroenterol 20(38):13833\u0026ndash;13843\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirai I, Kimura W, Kamigaichi Y et al (2010) The Triangle Operation: Radical resection concept involving lympho-neural clearance of the SMA, CA, and PV\u0026ndash;SMV confluence in pancreatic cancer surgery. Surgery 148(2):271\u0026ndash;278\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKatz MHG, Pisters PWT, Evans DB et al (2008) Borderline-resectable pancreatic cancer: The importance of vascular involvement and updated consensus definitions. Ann Surg Oncol 15(10):2803\u0026ndash;2811\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDel Chiaro M, Rangelova E, Blomberg J et al (2014) Venous resection during pancreatectomy for pancreatic cancer: A systematic review. HPB (Oxford) 16(8):715\u0026ndash;723\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlejzer A, Arvanitakis M, Loi P et al (2023) Impact of venous resection during pancreatoduodenectomy: A multicenter European study. Ann Surg 277(1):e129\u0026ndash;e138\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConroy T, Desseigne F, Ychou M et al (2011) FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 364:1817\u0026ndash;1825\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSohal DPS, Duong M, Ahmad SA et al (2019) Neoadjuvant therapy for pancreatic cancer: ASCO clinical practice guideline. J Clin Oncol 37(23):2082\u0026ndash;2088\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpringer S, Monteiro M, Jiao Y et al (2020) Circulating tumor DNA analysis in pancreatic cancer patients undergoing neoadjuvant therapy. Clin Cancer Res 26(10):2212\u0026ndash;2220\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoolsen MME, van Dam RM, Choi WJ et al (2013) Enhanced Recovery After Surgery in pancreatic surgery: A systematic review. Ann Surg 257(6):929\u0026ndash;936\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee MK, Javed AA, Zheng L et al (2019) ERAS shortens recovery and reduces complications after pancreatoduodenectomy. J Gastrointest Surg 23(4):771\u0026ndash;781\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraga M, Pecorelli N, Capretti G, Balzano G, Doglioni C, Gennari L (2012) Enhanced recovery after pancreatoduodenectomy: Pilot study in 100 consecutive patients. Med (Baltim) 91(3):e122\u0026ndash;e130\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Cairo University hospitals","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Triangle Operation, DeBakey Triad, Pancreaticoduodenectomy, Venous Resection, SMV–PV Reconstruction, Borderline-Resectable Pancreatic Cancer, ERAS, Technical Innovation","lastPublishedDoi":"10.21203/rs.3.rs-8239084/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8239084/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBorderline-resectable pancreatic head cancer with venous involvement demands an operative strategy that balances oncologic radicality, vascular precision, and postoperative recovery. We describe the DeBakey Triad, a unified technical framework integrating the Triangle Operation, Type III SMV–PV segmental venous resection, and Enhanced Recovery After Surgery (ERAS) principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnique Summary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DeBakey Triad consists of three interdependent elements performed in deliberate sequence:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRadical mesopancreatic excision (Triangle Operation) to expose the SMA, celiac axis, and SMV–PV confluence.\u003c/li\u003e\n \u003cli\u003eType III venous resection targeting the fixed post-neoadjuvant tumor–vessel interface, followed by primary SMV–PV end-to-end reconstruction.\u003c/li\u003e\n \u003cli\u003eStructured ERAS integration to support early physiological recovery and reduce postoperative morbidity.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis sequence standardizes both technical execution and perioperative workflow for anatomically complex pancreatic head cancers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIllustrative Application\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe demonstrate the technique using a post-neoadjuvant borderline-resectable case involving SMV–PV confluence involvement. The DeBakey Triad enabled an R0 resection, secure venous reconstruction, preserved postoperative venous patency, and safe discharge in \u0026lt; 100 hours.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DeBakey Triad represents an operative innovation that unifies radical dissection, formal venous resection, and enhanced recovery into a cohesive framework. This approach provides clarity, reproducibility, and physiologic advantage in the management of borderline-resectable pancreatic head cancer.\u003c/p\u003e","manuscriptTitle":"The DeBakey Triad: A Technical Innovation Integrating the Triangle Operation, Type III SMV–PV Resection, and ERAS in Pancreatic Head Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:58:20","doi":"10.21203/rs.3.rs-8239084/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb6b07a7-200d-4883-a6c3-18a183fbd176","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58825610,"name":"Surgery"}],"tags":[],"updatedAt":"2025-12-02T14:58:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:58:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8239084","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8239084","identity":"rs-8239084","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}