Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas

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.

European evidence-based guidelines on pancreatic cystic neoplasms

“… 79 Intraoperative main pancreatic duct (MPD) pancreatoscopy combined with frozen section of intraductal biopsies may be helpful in establishing the extent of IPMN involvement of the MPD, and assist surgical decision-making about the extent of resection required. 80 Although promising, further studies are required and it should not be used in routine clinical care. A major concern about nCLE is the rate of adverse events (7–9%).…”

“… 165–167 Moreover, detailed observation of the remnant MPD using intraoperative pancreatoscopy may provide identification of preoperatively undetected lesions. 80 168 169 Patients should always be counselled about the potential need for a total pancreatectomy.…”

Applications of Cholangiopancreatoscopy in Pancreaticobiliary Diseases

“…Narrow-band imaging offers a better detection of vascular patterns and protrusions and should be used whenever possible during POPS [120]. Intraoperative pancreatoscopy of the main PD combined with intraductal biopsies plays a significant role in the surgical management of patients with IPMNs and should be considered in all patients presenting with a sufficiently dilated main PD since it can alter the initial operative planning up to approximately 20% of cases [6,121]. Post-endoscopic ERCP pancreatitis is a well-known side effect of POPS and has been reported to happen in up to 17% of cases [116].…”

Cholangiopancreatoscopy

“…In 23.8% of patients, the initial operative plan was altered by an immediate read of pancreatoscopy direct biopsies. 107…”