Effect of warm and cold ischemia on pancreaticoduodenectomy specimen following robotic pancreaticoduodenectomy

Abstract

Background: The adoption of robotic pancreaticoduodenectomy (PD) has increased in recent years for the treatment of pancreatic head tumors and periampullary lesions. Some potential benefits seem to be demonstrated; however, obtaining specimens through this method can potentially compromise the diagnosis depending on the timing of the specimen retrieval, and the impact of longer perioperative time on ischemia and autolysis of the surgical specimen has not been analyzed. The aim of this study is to evaluate the histological changes associated with timing of specimen retrieval during robotic PD.

Methods: A review of histopathology files was performed for all pancreatic specimens collected at our hospital from January 2022 to March 2024. Both warm ischemia time (WIT) and cold ischemia time (CIT) were collected. Histological features related to ischemic damage were evaluated in normal duodenal and pancreatic parenchyma as well as pancreatic tumor, and were graded as: absent, mild, moderate and severe. Univariate and multivariate analyses were performed to determine which variables were associated with moderate and severe ischemic changes.

Results: Sixty surgical specimens were analyzed: 20 open PD, 17 robotic PD with cold ischemia, and 23 robotic PD. Median total WIT was 182 min (open PD 57 min vs. RPD 190 min vs. RPD-CI 198 min; p < 0.001). Median CIT was 760 min (740-835) in samples stored at 4ºC. Univariate analysis showed that longer intraoperative time, male gender and cold ischemia were associated with pancreatic tissue ischemic changes. In multivariate analysis, cold ischemia was the only independent factor associated with normal pancreatic tissue and tumor tissue moderate and severe ischemic changes.

Conclusions: Prolonged ischemia time, especially in the case of cold storage, has a strong effect on the degradation of normal and tumor tissue without affecting pathological evaluation. Operative teams should aim to optimize both the duration and efficiency of the surgical procedure, ensuring minimal ischemic time. Simultaneously, pathology departments must be equipped to process pancreatic specimens promptly, with protocols in place to minimize the time between resection and analysis.

Keywords: Cold ischemia; Robotic pancreaticoduodenectomy; Specimen damage; Warm ischemia.

Fig. 1

Flowchart diagram of patient inclusion. OPD; open pancreaticoduodenectomy, RPD; robotic pancreaticoduodenectomy

Fig. 2

Macroscopic appearance of robotic pancreaticoduodenectomy arrived at the Pathology Department right after surgery (A) showing firm and solid pancreatic parenchyma, and surgical specimen arrived 12 h after surgery (B), with gelatinous and friable parenchyma

Fig. 3

Microscopic appearance of surgical specimens. Representative images of normal duodenum (A), duodenum with mild (B) moderate (C) and severe (D) ischemic changes; normal pancreatic parenchyma (E) and pancreatic parenchyma with mild (F) moderate (G) and severe (H) ischemic changes; and adenocarcinoma without ischemic changes (I), and with mild (J) moderate (K) and severe (L) ischemic changes (x 20)