Intraoperative Imaging in Hepatopancreatobiliary Surgery

SIMPLE SUMMARY: There is evidence that oncological radicality with complete tumor removal may improve the survival of patients undergoing surgery for hepatopancreatobiliary malignancies. However, the complexity of vital vascular structures close to or embedded within the pancreas and the liver may increase both the surgical difficulty and the risk of achieving a non-radical resection. Preoperative staging after neoadjuvant therapy is usually challenged by the inability of correctly used imaging methods to distinguish vital tumors from fibrosis. Additionally, the inability to define the exact tumor borders often transfers to the operating room as well. Recently, more research has focused on the development of novel intraoperative imaging modalities and targeted contrast agents to improve preoperative and intraoperative diagnostics. We review current advances made in preclinical research and discuss clinical possibilities and future perspectives, including the characteristics of the ideal contrast agent. ABSTRACT: Hepatopancreatobiliary surgery belongs to one of the most complex fields of general surgery. An intricate and vital anatomy is accompanied by difficult distinctions of tumors from fibrosis and inflammation; the identification of precise tumor margins; or small, even disappearing, lesions on currently available imaging. The routine implementation of ultrasound use shifted the possibilities in the operating room, yet more precision is necessary to achieve negative resection margins. Modalities utilizing fluorescent-compatible dyes have proven their role in hepatopancreatobiliary surgery, although this is not yet a routine practice, as there are many limitations. Modalities, such as photoacoustic imaging or 3D holograms, are emerging but are mostly limited to preclinical settings. There is a need to identify and develop an ideal contrast agent capable of differentiating between malignant and benign tissue and to report on the prognostic benefits of implemented intraoperative imaging in order to navigate clinical translation. This review focuses on existing and developing imaging modalities for intraoperative use, tailored to the needs of hepatopancreatobiliary cancers. We will also cover the application of these imaging techniques to theranostics to achieve combined diagnostic and therapeutic potential.