Is intraoperative confirmation of malignancy during pancreaticoduodenectomy mandatory?

Introduction: Differentiating between chronic pancreatitis and pancreatic adenocarcinoma can be difficult due to considerable overlap in disease presentation and radiological signs and the frequent co-existence of the two conditions. In this situation, surgeons may have to proceed to "blind" pancreaticoduodenectomy or attempt to confirm malignancy intraoperatively with frozen section (FS) histology.

Methods: This study attempted to ascertain the false-negative and false-positive rates of undertaking pancreaticoduodenectomies (PD) based on clinical suspicion (CS) or after intraoperative confirmation of malignancy using FS histology.

Results: Of patients, 13.6% (nine out of 66) underwent a benign PD in the CS group; 6.7% of patients had a missed malignancy in the FS group (n = 62), but intraoperative histology prevented PD in 35% of patients with benign disease in the FS group. Specificity and sensitivity of intraoperative FS in detecting malignancy was 100% and 89.7%, respectively. Sensitivity of clinical assessment in detecting malignancy was 86.4%.

Conclusions: In experienced hands, intraoperative confirmation of malignancy is effective and will avoid resection in patients with benign disease. However, for many surgeons the chance of missing a small tumour with a false-negative biopsy will be unacceptable and they would prefer to undertake a "blind" resection and accept the mortality risk of pancreaticoduodenectomy for benign disease.