Surgical management of intraductal papillary mucinous tumors of the pancreas - The role of routine frozen section of the surgical margin, intraoperative endoscopic staged biopsies of the Wirsung duct, and pancreaticogastric anastomosis

Hypothesis: Resection of intraductal papillary mucinous tumors of the pancr eas (IPMTP) should be tailored to longitudinal spreading into the pancreati c ductal system and the presence of malignant transformation. Objective: To review a single institutional experience with IPMTP, focusing on the operative strategy of tailoring resection to the extent of disease. Design: Retrospective study. Settings Academic tertiary referral center. Patients: Thirteen patients with IPMTP were referred for resection during t he past 10 years. Malignant growth was present in 7 patients (54%). Accordi ng to the determination of tumor extent, distal pancreatic resection was pe rformed in 3 patients, pancreatoduodenectomy was done in 9 patients, and to tal pancreatectomy was performed in 1 patient. The median follow-up time in this series was 46 months (range, 3-104 months). Main Outcome Measures: Preoperative and perioperative diagnosis, final path ologic results, and longterm outcome, Results: A correct preoperative or perioperative diagnosis of IPMTP was ach ieved in 9 patients (69%). Routine frozen section of the surgical margin wa s used in all patients, changing the operative strategy in 3 (23%) of 13 pa tients by extending resection or leading to total pancreatectomy in 2 patie nts and 1 patient, respectively. A perioperative endoscopic examination of the Wirsung duct was performed in 3 patients with a correct preoperative or perioperative diagnosis of IPMTP and a dilated pancreatic duct. This allow ed the examination of the entire pancreatic ductal system and staged intrad uctal biopsies, changing the operative strategy in 1 of these patients. Fin ally, after pancreatoduodenectomy, pancreaticogastric anastomosis was const ructed in 5 patients, allowing endoscopic assessment of the pancreatic stum p during long-term follow-up. The 5-year actuarial survival rate was 56.8% in the whole series. All patients with benign or microinvasive malignant di sease remained disease-free, whereas all patients with invasive malignant d isease died of tumor recurrence. Conclusions: Accurate determination of the extent of ductal disease and res idual malignant growth, when present, is critical during surgical explorati on to achieve radical resection and cure. Operative strategy should be base d on routine frozen section of the surgical margin and perioperative endosc opic examination of the Wirsung duct with staged intraductal biopsies when technically feasible. The routine use of pancreaticogastric anastomosis aft er pancreatoduodenectomy allows easy, safe, and efficient long-term endosco pic assessment of the pancreatic stump.