Is the Use of Intraoperative Frozen Section During Pancreaticoduodenectomy Justified?

Intraoperative frozen section (IFS) is routinely utilized by many surgeons during pancreaticoduodenectomy. However, its utility has not been rigorously studied.

Patients who underwent pancreaticoduodenectomy between 2006 and 2015 were identified from institutional data. Measures of diagnostic accuracy of frozen section and multivariate logistic regression are reported.

The cohort included 1076 patients. Of resected specimens, 73.3% were malignant. IFS and final pathologic review (the gold standard) were discrepant for (1) pathologic diagnosis or (2) resection margin status in 5.3% and 3.3% of cases. The sensitivity, specificity, and accuracy of IFS for histologic determination of malignancy were 97.2%, 95.3%, and 96.7% respectively. For resection margins, they were 92.3%, 99.3%, and 96.8%, respectively. Positive bile duct and neck margins were revised intraoperatively 62% and 65% of the time, respectively; positive uncinate margins were never resected but led surgeons to avoid revision of a second positive margin in 13% of cases (4.2% of all PDA). Operative changes were rarely noted in the presence of benign disease (n = 11, 1.0%); conversion to total pancreatectomy based on positive margins was performed in just 13 cases (1.2%). Upon multivariable analysis, a positive neck margin proved to be the greatest predictor for a revised resection margin (AOR 16.9 [4.8-59.8]), whereas a positive uncinate margin or a diagnosis of chronic pancreatitis was protective against IFS-driven operative changes (AOR 0.25 [0.09-0.73]; AOR 0.16 [0.13-0.19]).

IFS is highly accurate and guides reresection of margins. However, selective omission of IFS may be justified for cases where benign disease is suspected.