Intraoperative Assessment of Pancreatic Neck Margin at the Time of Pancreaticoduodenectomy Increases Likelihood of Margin-negative Resection in Patients with Pancreatic Cancer

Background: The utility of intraoperative assessment of surgical margins is often debated by experienced pancreatic surgeons. We sought to review our experience with pancreaticoduodenectomy (PD) for pancreatic cancer to determine the impact of intraoperative frozen section (FS) analysis on margin-negative resection and long-term outcome.

Material And Methods: Between 1992 and 2007, 310 consecutive patients underwent PD at our institution; 223 of these were for pancreatic cancer. Seven patients who underwent R2 resection were excluded. Charts were reviewed to determine demographics, final pathology, perioperative course, and long-term outcome. Data were compared by Fisher's exact and Student's t tests. Survival curves were created using the Kaplan-Meier method and compared by log-rank analysis. Predictors of margin-negative resection were determined by logistic regression analysis and predictors of survival determined by Cox proportional hazards analysis.

Results: FS analysis of pancreatic neck resection margins was obtained in 75, while no intraoperative assessment was done in 141. Although patients who underwent FS were younger (median, 62 vs. 67 years, p = 0.01), the two groups were similar in terms of gender, comorbidities, preoperative stenting, pylorus preservation, tumor differentiation, nodal status, tumor size, length of stay, and complication rate. Margin-negative resection was more common when FS was undertaken (99% vs. 81%, p = 0.0001). However, intraoperative FS did not significantly increase overall survival (median, 21.7 vs. 14.6, p = 0.20). Only nodal metastasis was predictive of poor survival (median, 21.7 vs. 13.3 months, p = 0.001).

Conclusions: Intraoperative assessment of the pancreatic neck margin status at the time of PD for pancreatic cancer increases the likelihood of obtaining a margin-negative resection. Noteworthy is that final margin status was not predictive of survival, while only nodal metastasis was, suggesting that tumor biology is the most important factor in patients with pancreatic cancer.