Is the Use of Intraoperative Frozen Section During Pancreaticoduodenectomy Justified?

[Relevance of frozen section diagnostics in pancreatic surgery]

Frozen sections are performed in pancreatic surgery for three reasons: histopathological confirmation of previously unclear space-occupying lesions, determination of the extent of surgical resection in an operative exploration and for possible follow-up resections after previously carried out surgical resections. Overall, in the literature there are heterogeneous data with respect to an improvement in the prognosis of a secondary R0 resection by a repeat resection in comparison to a R1 resection. Nowadays, extended pancreatic resections including vascular resections are technically feasible and safe. Nevertheless, with respect to the precise radicality in the surgical procedure, all patient characteristics should be taken into consideration in addition to the histopathological diagnosis of the frozen sections.

Intraoperative Frozen Section Evaluation of Pancreatic Specimens and Related Liver Lesions

CONTEXT.—

Frozen sections are essential in the surgical management of patients, especially those with pancreatic masses, because frozen sections can provide answers intraoperatively and aid in treatment decisions. Pancreas frozen sections are challenging because of the small tissue size, processing artifacts, neoadjuvant treatment effects, and concurrent pancreatitis-like obstructive changes. The authors present a review of intraoperative evaluation of pancreatic specimens.

OBJECTIVE.—

To provide an approach to the diagnosis of pancreatic adenocarcinoma on frozen sections and to discuss commonly encountered pitfalls. Indications for pancreas frozen sections and specific margin evaluation will be discussed. We will also review frozen section diagnosis of subcapsular liver lesions and tumors other than metastases of pancreatic ductal adenocarcinoma.

DATA SOURCES.—

Data sources included a literature review and the personal experiences of the authors.

CONCLUSIONS.—

The features for diagnosis of pancreatic adenocarcinoma include disordered architecture, glands at abnormal locations, and atypical cytology. It is important to be aware of the pitfalls and clues on frozen section. The evaluation of resection margins can be challenging, and in the setting of the resection of cystic tumors, the key is the diagnosis of high-grade dysplasia or cancer. Finally, it is vital to remember the differential diagnosis for subcapsular liver lesions because not all lesions will be metastases of adenocarcinomas or bile duct adenomas. Frozen sections remain a useful tool for the intraoperative management of patients with pancreatic tumors.

The integration of artificial intelligence in robotic surgery: A narrative review

BACKGROUND

The rise of high-definition imaging and robotic surgery has independently been associated with improved postoperative outcomes. However, steep learning curves and finite human cognitive ability limit the facility in imaging interpretation and interaction with the robotic surgery console interfaces. This review presents innovative ways in which artificial intelligence integrates preoperative imaging and surgery to help overcome these limitations and to further advance robotic operations.

METHODS

PubMed was queried for "artificial intelligence," "machine learning," and "robotic surgery." From the 182 publications in English, a further in-depth review of the cited literature was performed.

RESULTS

Artificial intelligence boasts efficiency and proclivity for large amounts of unwieldy and unstructured data. Its wide adoption has significant practice-changing implications throughout the perioperative period. Assessment of preoperative imaging can augment preoperative surgeon knowledge by accessing pathology data that have been traditionally only available postoperatively through analysis of preoperative imaging. Intraoperatively, the interaction of artificial intelligence with augmented reality through the dynamic overlay of preoperative anatomical knowledge atop the robotic operative field can outline safe dissection planes, helping surgeons make critical real-time intraoperative decisions. Finally, semi-independent artificial intelligence-assisted robotic operations may one day be performed by artificial intelligence with limited human intervention.

CONCLUSION

As artificial intelligence has allowed machines to think and problem-solve like humans, it promises further advancement of existing technologies and a revolution of individualized patient care. Further research and ethical precautions are necessary before the full implementation of artificial intelligence in robotic surgery.

Utility of intraoperative pathology consultations of whipple resection specimens and their impact on final margin status

The resection margin status is a significant surgical prognostic factor for the long-term outcomes of patients undergoing pancreaticoduodenectomy (Whipple procedure). As a result, surgeons frequently rely on intraoperative consults (IOCs) involving frozen sections to evaluate margin clearance during these resections. Nevertheless, the impact of this practice on final margin status and long-term outcomes remains a topic of debate. This study aimed to assess the impact of IOCs on the clearance rate of resection margins following Whipple procedure and distal pancreatectomy. A retrospective database review of all patients who underwent Whipple procedure or distal pancreatectomy at our institution between 2018 and 2020 was performed to evaluate the utility of IOCs by gastrointestinal surgeons and its correlation with final postoperative surgical margin status. A significant variation in the frequency of IOC requests for margins among surgeons was noted. However, the use of frozen section analysis for intraoperative margin assessment was not significantly associated with the clearance rate of final post-operative margins. More frequent use of IOC did not result in higher final margin clearance rate, an important prognostic factor following Whipple procedure.

Routine frozen section during pancreaticoduodenectomy does not improve value-based care

Introduction

Frozen section (FS) is often performed to confirm negative margins during pancreaticoduodenectomies (PD). This incurs significant cost, despite lack of evidence of survival benefit. We sought to determine the frequency of positive FS during PD, associated costs per positive margin identified, and association with locoregional recurrence (LRR) and overall survival (OS).

Methods

A database of 526 PDs performed from 2014 to 2017 at a multi-institution integrated health-care system was queried. Charts and imaging were reviewed for systemic treatment, FS and PM results, pathologic stage, LRR and OS. Direct facility and professional costs for FS were determined from billing data. Cox proportional hazards for LRR and OS were performed.

Results

9.2% of all initial FS were positive. Average cost per FS was $148, with a cost of $1,538 per positive FS identified. Positive FS was not associated with LRR (HR 1.32, 95% CI: 0.50-3.52, p = 0.58) or median OS (25.9 vs 36.2 months, p = 0.38).

Conclusion

Routine FS during PD is a low-yield test with significant associated costs. Positive FS was not associated with locoregional recurrence or overall survival. Routine FS does not provide substantial benefit for value-based care when performing PD.

Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground

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.

Margin-Positive Pancreatic Ductal Adenocarcinoma during Pancreaticoduodenectomy: Additional Resection Does Not Improve Survival

BACKGROUND

The impact of resecting positive margins during pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA) remains debated. Additionally, the survival benefit of resecting multiple positive margins is unknown.

METHODS

We identified patients with PDA who underwent PD from 2006 to 2015. Pancreatic neck, bile duct, and uncinate frozen section margins were assessed before and after resection of positive margins. Survival curves were compared with log-rank tests. Multivariable Cox regression assessed the effect of margin status on overall survival.

RESULTS

Of 501 patients identified, 17.3%, 5.3%, and 19.7% had an initially positive uncinate, bile duct, or neck margin, respectively. Among initially positive bile duct and neck margins, 77.8% and 67.0% were resected, respectively. Although median survival was decreased among patients with any positive margins (15.6 vs. 20.9 months; p = 0.006), it was similar among patients with positive bile duct or neck margins with or without R1 to R0 resection (17.0 vs. 15.6 months; p = 0.20). Median survival with and without positive uncinate margins was 13.8 vs. 19.7 months (p = 0.04). Uncinate margins were never resected. Resection of additional margins when the uncinate was concurrently positive was not associated with improved survival (p = 0.37). Patients with positive margins who received adjuvant therapy had improved survival, regardless of margin resection (p = 0.03). Adjuvant therapy was independently protective against death (hazard ratio 0.6, 95% CI 0.5-0.7).

CONCLUSIONS

Positive PD margins at any position are associated with reduced overall survival; however, resection of additional margins may not improve survival, particularly with concurrently positive uncinate margins. Adjuvant chemotherapy improves survival with positive margins, regardless of resection.