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Grewal M, Habib JR, Paluszek O, Cohen SM, Wolfgang CL, Javed AA. The Role of Intraoperative Pancreatoscopy in the Surgical Management of Intraductal Papillary Mucinous Neoplasms: A Scoping Review. Pancreas 2024; 53:e280-e287. [PMID: 38277399 DOI: 10.1097/mpa.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
OBJECTIVES Most patients with intraductal papillary mucinous neoplasms (IPMNs) are diagnosed with a solitary lesion; however, the presence of skip lesions, not appreciable on imaging, has been described. Postoperatively, these missed lesions can continue to grow and potentially become cancerous. Intraoperative pancreatoscopy (IOP) may facilitate detection of such skip lesions in the remnant gland. The aim of this scoping review was to appraise the evidence on the role of IOP in the surgical management of IPMNs. MATERIALS AND METHODS Studies reporting on the use of IOP during IPMN surgery were identified through searches of the PubMed, Embase, and Scopus databases. Data extracted included IOP findings, surgical plan modifications, and patient outcomes. The primary outcome of interest was the utility of IOP in surgical decision making. RESULTS Ten studies reporting on the use of IOP for IPMNs were identified, representing 147 patients. A total of 46 skip lesions were identified by IOP. Overall, surgical plans were altered in 37% of patients who underwent IOP. No IOP-related complications were reported. CONCLUSIONS The current literature suggests a potential role of integration of IOP into the management of patients with IPMNs. This tool is safe and feasible and can result in changes in surgical decision making.
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Affiliation(s)
- Mahip Grewal
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Joseph R Habib
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Steven M Cohen
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Christopher L Wolfgang
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Ammar A Javed
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
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2
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Ciprani D, Frampton A, Amar H, Oppong K, Pandanaboyana S, Aroori S. The role of intraoperative pancreatoscopy in the surgical management of intraductal papillary mucinous neoplasms of the pancreas: a systematic scoping review. Surg Endosc 2023; 37:9043-9051. [PMID: 37907657 DOI: 10.1007/s00464-023-10518-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/08/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND The type and the extent of surgery is still debatable for intraductal papillary mucinous neoplasm (IPMN). Intraoperative pancreatoscopy (IOP) allows the visualization of the main pancreatic duct (MPD) in its entire length and could help determine the extent of MPD involvement and the type and extent of pancreatic resection. However, current guidelines do not advise its routine use as there is a lack of evidence supporting its safety and feasibility. The present study aims to perform a scoping review of published evidence on the safety and feasibility of IOP in IPMN surgical management. METHODS We systematically searched PubMed, Cochrane, Medline and EMbase to identify studies reporting the use of IOP in IPMN surgical management. The research was completed in June 2023. Data extracted included patient selection criteria, demographics, safety of the procedure, intraoperative findings, impact on surgical strategy, histology results and postoperative outcomes. RESULTS Four retrospective and one prospective study were included in this scoping review. A total of 142 patients had IOP. The selection criteria for inclusion were heterogenous, with one out of five studies including branch duct (BD), main duct (MD) and mixed type IPMN. Indications for IOP and surgical resection were only reported in two studies. A median of seven outcomes (range 5-8) was described, including the type of surgical resection, additional lesions and change of surgical plan, and complications after IOP. IOP showed additional lesions in 48 patients (34%) and a change of surgical plan in 48(34%). No IOP-related complications were reported. CONCLUSIONS This scoping review suggests IOP is safe and identifies additional lesions impacting the surgical strategy for IPMN. However, the included studies were small and heterogeneous regarding IPMN definition and indications for surgery and IOP. There is a need for a large multi-centre prospective study to determine the role of IOP and its impact on surgical strategy for IPMN.
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Affiliation(s)
- Debora Ciprani
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Adam Frampton
- Department of HPB Surgery, Royal Surrey County NHS Foundation Trust, Guildford, UK
| | - Hoda Amar
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kofi Oppong
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK.
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3
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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4
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Arnelo U, Valente R, Scandavini CM, Halimi A, Mucelli RMP, Rangelova E, Svensson J, Schulick RD, Torphy RJ, Fagerström N, Moro CF, Vujasinovic M, Matthias Löhr J, Del Chiaro M. Intraoperative pancreatoscopy can improve the detection of skip lesions during surgery for intraductal papillary mucinous neoplasia: A pilot study. Pancreatology 2023; 23:704-711. [PMID: 37336668 DOI: 10.1016/j.pan.2023.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Intraoperative pancreatoscopy is a promising procedure that might guide surgical resection for suspected main duct (MD) and mixed type (MT) intraductal papillary mucinous neoplasms (IPMNs). The aim of the present study was to assess the diagnostic yield and clinical impact of intraoperative pancreatoscopy in patients operated on for MD and MT-IPMNs. METHODS This is a retrospective cohort study. Patients undergoing surgery for suspected MD or MT-IPMN underwent intraoperative pancreatoscopy and frozen section analysis. In all patients who required extended resection due to pancreatoscopic findings, we compared the final histology with the results of the intraoperative frozen section analysis. RESULTS In total, 46 patients, 48% females, mean age (range) 67 years (45-82 years) underwent intraoperative pancreatoscopy. No mortality or procedure related complications were observed. Pancreatoscopy changed the operative course in 30 patients (65%), leading to extended resections in 20 patients (43%) and to parenchyma sparing procedures in 10 patients (22%). Analyzing the group of patients who underwent extended resections, 7 (35%) displayed lesions that needed further surgical treatment (six high grade dysplasia and one with G1 pancreatic neuroendocrine tumor) and among those 7, just 1 (14%) would have been detected exclusively with histological frozen section analysis of the transection margin. The combination of both pancreatoscopy and frozen section analysis lead to 86% sensitivity and 92% specificity for the detection of pathological tissue in the remnant pancreas. CONCLUSION Intraoperative pancreatoscopy is a safe and feasible procedure and might allow the detection of skip lesions during surgery for suspect MD-involving IPMNs.
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Affiliation(s)
- Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Raffaella M Pozzi Mucelli
- Department of Radiology Huddinge, Karolinska University Hospital, O-huset 42, 14186, Stockholm, Sweden; Division of Radiology, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Section for Upper Abdominal Surgery at Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niklas Fagerström
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Carlos Fernández Moro
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Huddinge, Sweden; Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Huddinge, Sweden
| | - Miroslav Vujasinovic
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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5
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Fong ZV, Zwart MJ, Gorris M, Voermans RP, van Wanrooij RL, Wielenga T, del Chiaro M, Arnelo U, Daams F, Busch OR, Besselink MG. Intraoperative Pancreatoscopy During Robotic Pancreatoduodenectomy and Robotic Distal Pancreatectomy for Intraductal Papillary Mucinous Neoplasm with Involvement of the Main Pancreatic Duct. ANNALS OF SURGERY OPEN 2023; 4:e283. [PMID: 37601466 PMCID: PMC10431574 DOI: 10.1097/as9.0000000000000283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/02/2023] [Indexed: 08/22/2023] Open
Abstract
Background Intraductal papillary mucinous neoplasm (IPMN) with involvement of the main pancreatic duct usually requires surgical resection. Consensus is lacking whether to partially or completely resect the pancreatic portion with a dilated main pancreatic duct. Intraoperative pancreatoscopy may be useful to determine the extent of IPMN to tailor surgical resection and was recently studied in a large prospective international study. IPMN is increasingly utilized using a robotic approach. Studies describing the technical approach to intraoperative pancreatoscopy in robotic pancreatoduodenectomy and robotic distal pancreatectomy are lacking. Methods During robotic pancreatoduodenectomy, pancreatoscopy is performed once the pancreas neck is transected. The scope is advanced via a laparoscopic port into the left and right-sided pancreatic duct, guided by robotic graspers. During robotic distal pancreatectomy, pancreatoscopy is performed before complete parenchymal transection. The scope is advanced through an anterior ductotomy to examine the duct and guide the pancreatic transection line. Tips and tricks how to perform the procedure efficiently without complications are detailed. Results In total, 28 robot-assisted pancreatoscopies were performed during robotic pancreatoduodenectomy and robotic distal pancreatectomy. No intraoperative complications resulting from the intraoperative pancreatoscopy were noted. In the 2 described procedures, the added time required to perform the pancreatoscopy was 6 and 17 minutes, respectively. Both patients recovered without complication and were discharged on postoperative day 5 for the robotic pancreatoduodenectomy and day 6 for the robotic distal pancreatectomy. Conclusions Intraoperative pancreatoscopy can be safely performed during both robotic pancreatoduodenectomy and robotic distal pancreatectomy for IPMN with the involvement of the main pancreatic duct. An international prospective study has recently been completed with this technique.
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Affiliation(s)
- Zhi Ven Fong
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Dana Farber Cancer Institute, Mass General Brigham, Harvard Medical School, Boston, MA
- Cancer Center Amsterdam, the Netherlands
| | - Maurice J.W. Zwart
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Myrte Gorris
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P. Voermans
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Roy L.J. van Wanrooij
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Thijs Wielenga
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Urban Arnelo
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Freek Daams
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Olivier R. Busch
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Marc G. Besselink
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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Intraoperative pancreatoscopy in pancreaticoduodenectomy for intraductal papillary mucinous neoplasms of the pancreas: Application to the laparoscopic approach. Asian J Surg 2023; 46:166-173. [PMID: 35331591 DOI: 10.1016/j.asjsur.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/30/2021] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND /Purpose: Owing to the characteristics of IPMNs, which have variable skipped lesions along the main pancreatic duct (MPD), determining the surgical margins is very difficult. This study aimed to investigate the efficacy and potential oncologic impact of intraoperative pancreatoscopy (IOP) compared to frozen section biopsy (FSB) in pancreaticoduodenectomy (PD) for pancreatic head IPMNs. METHODS Data of patients who underwent PD for IPMNs of the pancreas between October 2007 and May 2020 were retrospectively reviewed. IOP was performed in selected patients with IPMNs with inconclusive MPD involvement based on preoperative evaluations. Patients were divided into two groups, IOP group, FSB group. Clinicopathologic features and oncologic outcomes were compared between two groups. RESULTS 60 patients underwent PD (laparoscopic or robotic, 42; open, 18) for pancreatic head IPMNs. IOP was safely performed in 28 patients, including minimally invasive approach used in 21 patients (35%). IOP group had a significantly larger MPD size (9.15 ± 4.79 mm vs 6.43 ± 4.11 mm, p = 0.021). Based on IOP, the initial surgical plan could be changed in 5 patients (17.8%) for complete resection. Recurrence occurred in 2 patients in FSB group and 3 patients in IOP group during the follow-up period (33.2 months, [range, 3.5-131.4 months]). Overall disease-free survival rate did not significantly differ between two groups (p = 0.529). CONCLUSIONS IOP can be safely performed in patients with pancreatic head IPMNs with MPD dilatation, even in the laparoscopic approach. Further studies evaluating the long-term oncologic effect of IOP for the management of IPMNs are required.
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Hedjoudje A, Dokmak S, Cros J, Sauvanet A, Prat F. Laparoscopic intraoperative pancreatoscopy for main duct intraductal papillary mucinous neoplasms assessment. VideoGIE 2022; 8:27-29. [PMID: 36644252 PMCID: PMC9832246 DOI: 10.1016/j.vgie.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Video 1Intraoperative pancreatoscopy during laparoscopic pancreatic resection for main pancreatic duct intraductal papillary mucinous neoplasms.
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Affiliation(s)
- Abdellah Hedjoudje
- Service d’Endoscopie Digestive, DMU DIGEST, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France,Service de Pancréatologie, DMU DIGEST, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France
| | - Safi Dokmak
- Service de Chirurgie Hépato-Biliaire, DMU DIGEST, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France
| | - Jérôme Cros
- Service d’Anatomopathologie, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France
| | - Alain Sauvanet
- Service de Chirurgie Hépato-Biliaire, DMU DIGEST, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France
| | - Frédéric Prat
- Service d’Endoscopie Digestive, DMU DIGEST, Beaujon Hospital, Assistance Publique Hopitaux de Paris (APHP), Clichy, France
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de Jong DM, Stassen PMC, Groot Koerkamp B, Ellrichmann M, Karagyozov PI, Anderloni A, Kylänpää L, Webster GJM, van Driel LMJW, Bruno MJ, de Jonge PJF. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. Endoscopy 2022; 55:25-35. [PMID: 35668651 PMCID: PMC9767751 DOI: 10.1055/a-1869-0180] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. METHODS The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. RESULTS 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. CONCLUSION POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pauline M. C. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark Ellrichmann
- Department of Interdisciplinary Endoscopy, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Petko I. Karagyozov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda University Hospital, Sofia, Bulgaria
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Leena Kylänpää
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - George J. M. Webster
- Department of Gastroenterology, University College London Hospitals, London, UK,Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Lydi M. J. W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter J. F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Crippa S, Belfiori G, Tamburrino D, Partelli S, Falconi M. Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground. Updates Surg 2021; 73:1219-1229. [PMID: 34331677 DOI: 10.1007/s13304-021-01141-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 12/23/2022]
Abstract
The extension of a partial pancreatectomy up to total pancreatectomy because of positive neck margin examined at intraoperative frozen section (IFS) analysis is an accepted procedure in modern pancreatic surgery with good accuracy. The goal of this practice is to improve the rate of radical (R0) resection in malignant tumors, mainly pancreatic ductal adenocarcinoma (PDAC), and to completely resect pre-invasive neoplasms such as intraductal papillary mucinous neoplasms (IPMNs). In the setting of IPMNs there is a consensus for pancreatic re-resection when high-grade dysplasia and invasive cancer are present at the neck margin. The presence of denudation is another indication for further resection in IPMNs. The role of IFS analysis in the management of pancreatic cancer is more debated. The presence of a positive intraoperative transection margin can be considered the surrogate of a biologically aggressive disease associated with a poorer prognosis. There are conflicting data regarding possible advantages of pancreatic re-resection up to total pancreatectomy, and the lack of randomized trials comparing different strategies does not offer a definitive answer. The goal of this review is to provide an up-to-date overview of the role IFS analysis of pancreatic margin and of pancreatic re-resection up to total pancreatectomy considering different pancreatic tumors.
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Affiliation(s)
- Stefano Crippa
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giulio Belfiori
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Stefano Partelli
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy. .,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy. .,Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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10
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Congiusta A, Brown A, Brown AM, Yeo CJ. Intraoperative Pancreatic Ductoscopy for Ampullary Adenocarcinoma During Pancreatic Resection: A Case Report. J Pancreat Cancer 2019; 5:58-61. [PMID: 31608317 PMCID: PMC6786337 DOI: 10.1089/pancan.2019.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Periampullary neoplasms can be challenging to work up and diagnose preoperatively. Herein, we report the case of a patient whose preoperative workup failed to detect a malignancy, yet, underwent a pylorus-preserving pancreaticoduodenectomy (PPPD) with intraoperative pancreatic ductoscopy (IPD) and was ultimately found to have an ampullary adenocarcinoma. Presentation: A 78-year-old woman presented with 4 weeks of nausea, weight loss, jaundice, and light-colored stools. She underwent outpatient diagnostic studies, including magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography with pancreatic duct (PD) stenting and papillotomy. These revealed common bile duct dilatation measuring 2 cm, PD dilatation measuring 7 mm, a 17 mm cyst in the head of the pancreas, and a firm nodule noted between the biliary and pancreatic orifices. Cytologic and pathologic analyses were initially nondiagnostic. A repeat ampullary biopsy was negative for dysplasia and malignancy. A computed tomography scan was then performed and showed cystic pancreatic lesions with pancreatic ductal dilation. Suspicion remained high for periampullary tumor or a main duct intraductal papillary mucinous neoplasm, and the patient underwent a PPPD with IPD and tolerated the procedure well. Her final specimen pathology revealed well-to-moderately differentiated ampullary adenocarcinoma, pancreaticobiliary type with positive nodal disease. Conclusions: Given the relatively poor prognosis of patients with node-positive pancreaticobiliary-type ampullary adenocarcinoma, clinical suspicion should remain high for malignancy in patients with lesions located in the periampullary region and a negative preoperative workup, as aggressive treatment approaches are warranted to maximize their chance for survival.
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Affiliation(s)
- Anthony Congiusta
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ariel Brown
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew M Brown
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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Navez J, Hubert C, Gigot JF, Borbath I, Annet L, Sempoux C, Lannoy V, Deprez P, Jabbour N. Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas. J Am Coll Surg 2015; 221:982-7. [PMID: 26304184 DOI: 10.1016/j.jamcollsurg.2015.07.451] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/19/2015] [Accepted: 07/27/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium. STUDY DESIGN Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination. RESULTS Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery. CONCLUSIONS Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.
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Affiliation(s)
- Julie Navez
- Unit of Hepato-biliary and Pancreatic Surgery, Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Catherine Hubert
- Unit of Hepato-biliary and Pancreatic Surgery, Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Jean-François Gigot
- Unit of Hepato-biliary and Pancreatic Surgery, Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Ivan Borbath
- Department of Hepato-Gastro-Enterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Laurence Annet
- Department of Imaging study, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Christine Sempoux
- Department of Pathology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Valérie Lannoy
- Cancer Center Institute Roi Albert II, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Pierre Deprez
- Department of Hepato-Gastro-Enterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Nicolas Jabbour
- Unit of Hepato-biliary and Pancreatic Surgery, Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Brussels, Belgium.
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