Is intraoperative confirmation of malignancy during pancreaticoduodenectomy mandatory?

Application of intraoperative transluminal core-biopsy for diagnosis of pancreatic head mass: A single center 15-year experience

BACKGROUND

Pathology is the gold standard for diagnosis of pancreatic cancer. Preoperative endoscopic ultrasound-guided biopsy is an expensive procedure that is not routine in developing countries, hence a cheap, reliable alternative is required.

AIM

To evaluate the effectiveness and safety of a new technique of intraoperative biopsy from pancreatic head mass.

METHODS

Patients undergoing intraoperative transluminal core-biopsy (TLCB) for pancreatic head mass from January 2000 to June 2015 were included in this study. Following Kocher's maneuver, a biopsy was taken from the mass through the duodenum transluminally, using a commercial 16G automatic core-biopsy needle. Multiple tissue specimens were obtained for intraoperative frozen section examination. Depending on the pathological results, a decision was taken to either perform pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, bypass surgery, or to just terminate the operation. The malignancy status of the lesion was confirmed by postoperative pathological examination and/or long-term follow-up of the patients.

RESULTS

A total of 525 patients were included. Intraoperative pathological reports revealed 436 malignant cases and 89 cases without evidence of malignancy. The sensitivity, specificity, false positive rate, and false negative rate were 97.7%, 100%, 0%, and 2.3%, respectively. Complications occurred in 2 patients.

CONCLUSION

TLCB is a quick, safe, effective, and accurate method for intraoperative diagnosis method in patients with pancreatic head mass; it can provide reliable evidence for surgical decision-making.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis

BACKGROUND

The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease.

METHODS

Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ).

RESULTS

No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509).

CONCLUSION

Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

[Surgical management of chronic pancreatitis complicated by biliary and duodenal obstruction]

AIM

To compare different surgical approaches to chronic pancreatitis complicated by biliary and duodenal obstruction.

MATERIAL AND METHODS

In the study (n=42) and control (n=36) groups 18 and 4 resections were performed respectively (p=0.004). Early postoperative complications occurred in 15 cases of the study group and 4 cases of the control group (p=0.024). 7 and 1 re-operations were made in both groups respectively (p=0.99). There was no postoperative mortality in both groups. There were 4 cases of return to false-negative results of intraoperative biopsy in the control group. In these patients resection was possible during primary surgery.

CONCLUSION

Resections are advisable for chronic pancreatitis complicated by obstructive jaundice and duodenal obstruction because it eliminates biliary and duodenal obstruction and can accurately determine the nature of disease.

Endoscopic ultrasound-guided sampling in gastroenterology: European society of gastrointestinal endoscopy technical guidelines

At present, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines on endoscopic ultrasound-guided sampling are almost complete and express state of the art developments. However, future developments are anticipated. This editorial focuses on a few recently published papers with some additional information and on two important additional techniques, elastography and contrast enhanced ultrasound (CEUS), which are mentioned, but not explained in detail in the current ESGE guidelines. Elastography and CEUS might be of importance in the near future to improve the biopsy techniques.

When to perform a pancreatoduodenectomy in the absence of positive histology? A consensus statement by the International Study Group of Pancreatic Surgery

BACKGROUND

Pancreatoduodenectomy (PD) provides the best chance for cure in the treatment of patients with localized pancreatic head cancer. In patients with a suspected, clinically resectable pancreatic head malignancy, the need for histologic confirmation before proceeding with PD has not historically been required, but remains controversial.

METHODS

An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature and worked together to establish a consensus on when to perform a PD in the absence of positive histology.

RESULTS

The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by endoscopic cholangiopancreatography brushings and percutaneous fine-needle aspiration are highly specific, but poorly sensitive. Aspiration biopsy guided by endoscopic ultrasonography (EUS) has greater sensitivity, but it is highly operator dependent and increases expense. The incidence of autoimmune pancreatitis (AIP) in the benign resected specimens is 30-43%. EUS-guided Trucut biopsy, serum levels of immunoglobulin G4, and HISORt (Histology, Imaging, Serology, Other organ involvement, and Response to therapy) are used for diagnosis. If AIP is suspected but not confirmed, the response to a short course of steroids is helpful for diagnosis.

CONCLUSION

In the presence of a solid mass suspicious for malignancy, consensus was reached that biopsy proof is not required before proceeding with resection. Confirmation of malignancy, however, is mandatory for patients with borderline resectable disease to be treated with neoadjuvant therapy before exploration for resection. When a diagnosis of AIP is highly suspected, a biopsy is recommended, and a short course of steroid treatment should be considered if the biopsy does not reveal features suspicious for malignancy.

Surgically proved visually isoattenuating pancreatic adenocarcinoma undetected in both dynamic CT and MRI. Was blind pancreaticoduodenectomy justified?

INTRODUCTION

Visually isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on CT and recognizable only by secondary imaging signs. The frequency of isoattenuating pancreatic adenocarcinomas at dynamic-enhanced CT has been reported to range from 5.4% to 14%. Furthermore, 80% of the visually isoattenuating pancreatic adenocarcinomas are detectable in dynamic-enhanced MRI. Consequently, a pancreatic adenocarcinoma undetected in both the above imaging studies is an exceptionally rare event.

PRESENTATION OF CASE

The present report describes a case of a histologically proved 3.5cm pancreatic adenocarcinoma undetected in both dynamic-enhanced CT and MRI. The patient presented with progressive jaundice over the preceding 20 days. Initial abdominal CT showed a dilated pancreatic and common bile duct without demonstration of a lesion responsible for the clinical and imaging findings. Additional diagnostic work-up with dynamic CT and dynamic MRI failed to reveal a definitive mass. ERCP revealed an irregular interruption of the pancreatic and distal common bile duct with upstream dilation. Blind radical pancreaticoduodenectomy was performed. Histologic examination showed a pT3pN1MO pancreatic ductal adenocarcinoma of the head/neck.

DISCUSSION

Isoattenuating pancreatic adenocarcinoma patients represent a small but meaningful subset of patients with pancreatic cancer, as they have better survival. The more favorable postsurgical survival makes it even more imperative to correctly diagnose their cases at early stages by obtaining further diagnostic work-up with dynamic pancreatic CT, dynamic MRI and endoscopic ultrasound.

CONCLUSION

When the above studies fail to unmask the lesion, blind pancreaticoduodenectomy should be based on strong clinical suspicion and secondary imaging findings.

Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report

Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.