br IOUS intraoperative ultrasound PPPD
IOUS = intraoperative ultrasound; PPPD = pylorus preserving pancreatoduodectomy.
on preoperative imaging, and in one of these patients, the vascular contact could also not be assessed with IOUS.
The analysis revealed that contact (or lack of con-tact) between the tumor and the vascular groove
(including SMA and SMV resection margins) was cor-rectly assessed using preoperative imaging in 20 of the 27 procedures (74%) and that IOUS assessment was cor-rect in 24 of the 27 procedures (89%), which did not
Fig. 1. IOUS images corresponding to influences on surgical strategy. (a) vascular involvement: Vena Porta (VP) >120⁰ contact with tumor (*); therefore, resection with VP patch was necessary. (b) tumor localization: The tumor (*) is in the anterior duodenal wall, caudal from the papilla. The duodenal border is intact, and only minimal edema is found in the pancreatic fat (P); therefore, only a BYL-719 resection was performed. (c) waiving resection: Ingrowth of a conglomer-ate of the tumor (*) is found in branches of the superior mesenteric artery, which was not identified on preoperative imag-ing. Doud. = duodenum; IOUS = intraoperative ultrasound; LN = lymph node; Lumen = lumen of duodenum; PD = ductus pancreaticus; VP = vena porta.
Table 4. Vascular contact assessed during pathologic examina-tion compared with preoperative imaging and IOUS assessment
No contact Vascular Contact cannot
contact be judged
Vascular 2 5 2
Vascular 1 8
IOUS = intraoperative ultrasound; PA = pathologic analysis.
In one patient, pathologic evaluation revealed contact of both the SMA margin and the SMV margin, but during the preoperative imaging and IOUS assessment, only contact with the SMV was established. Therefore, this patient is not included in the table.
significantly differ from each other (p value = 0.21). Moreover, contact (or lack of contact) between the tumor and solely the SMV (including PV and the confluence) was assessed correctly using preoperative imaging in 21 of the 27 procedures (78%), and IOUS assessment was correct in 25 out of 27 tumors (93%). These also did not significantly differ from each other (p value = 0.06). All of the tumors that had no vascular contact were radically resected (R0).
Finally, the four patients that received neoadjuvant chemotherapy were evaluated on an individual basis. In one patient, no vascular contact or vascular involvement was visible using either preoperative imaging or IOUS. Unfortunately, as tumor involvement was found at the
gastroduodenal artery resection margin, this resection margin was not assessed using IOUS, and during micro-scopic examination, only a small cluster of tumor cells was identified. In the second patient, neither vascular contact nor vascular involvement could be determined using preoperative imaging; in contrast, IOUS revealed contact between the tumor and the PV. However, it remained unclear whether this was tumor tissue or fibrotic tissue. Eventually, the tumor was peeled away from the PV and was radically resected; therefore, the tissue was likely fibrotic tissue. In the third patient, no vascular contact or vascular involvement was visible using preoperative imaging; IOUS showed a mass with characteristics suggestive of a complete response (Fig. 2). Since the tumor responded completely to the neoadjuvant chemotherapy, the fibrotic mass is hard to distinguish on Figure 2. The complete response was con-firmed by microscopic examination. Lastly, in the fourth patient, vascular contact between the tumor and the SMV and/or PV could not be determined reliably based on preoperative imaging. In this case, IOUS revealed that the distance between the tumor and the SMV/PV was 16 mm; thus, the tumor could be removed radically without vascular resection as was confirmed with PA.