# Intraoperative Elastography in Pancreatic Cancer—Clinical Applications and Systematic Review of the Literature

## TL;DR

Intraoperative elastography shows promise in identifying pancreatic cancer and predicting surgical complications like pancreatic fistulas, but more research is needed for clinical use.

## Contribution

This paper systematically reviews the use of intraoperative elastography for pancreatic tumor characterization and POPF prediction, providing exploratory cut-off values.

## Key findings

- Intraoperative SWE can detect pancreatic cancer with cut-off values of 3 m/s and 28.7 kPa.
- Values of 2.2 m/s or less are an independent risk factor for postoperative pancreatic fistula.
- Further studies are needed to validate these cut-off values for routine clinical use.

## Abstract

Pancreatic cancer (PC) is an aggressive disease that is expected to be the second leading cause of cancer-related death by 2030. Overall survival of patients with PC is often limited to only a few months, since most of the patients present with locally advanced tumors. Radical surgical resection with R0 margins remains the only available curative treatment, capable of improving survival rates in patients with PC; thus, appropriate characterization of pancreatic tumors is mandatory for correct assessment of PC resectability. Moreover, surgical management in pancreatic surgery must take into consideration the texture of the pancreas. Postoperative pancreatic fistula (POPF) is a major complication that can negatively influence morbidity and mortality in pancreatic surgery, and soft pancreatic texture is considered an independent risk factor for POPF. Unfortunately, evaluation of pancreatic parenchyma is mainly performed via subjective methods (like intraoperative surgeon’s palpation). Intraoperative elastography has been used in PC lesions characterization and real-time evaluation of the pancreatic parenchyma, and could be a promising tool in assessing pancreatic stiffness and predicting the risk of POPF in pancreatic surgery.

Background: Pancreatic cancer (PC) is expected to be the second leading cause of cancer-related death by 2030. Surgical resection with R0 margins remains the only available treatment capable of improving the overall survival of the patients; thus, appropriate characterization of pancreatic tumors is mandatory for the correct assessment of PC resectability. Despite advances in pancreatic surgery, POPF remains a frequent and dreaded complication that impacts the morbidity and mortality of PC patients, entailing both clinical and economic consequences. Soft pancreatic texture is known as an independent risk factor for POPF occurrence in pancreatic surgery. Intraoperative exploration of the pancreas is most frequently assessed subjectively, through the surgeon’s palpation. Intraoperative elastography is a modern ultrasound technique suitable to replace the surgeon’s intraoperative palpation to better evaluate pancreatic lesions, pancreatic texture, and improve surgical management. Thus, intraoperative elastography could provide quantifiable and reproducible information in pancreatic parenchyma characterization. Real-time intraoperative assessment of pancreatic texture through an objective method could improve surgical decisions. This systematic review analyzes the role of intraoperative elastography in differentiating benign from malignant pancreatic tumors and the efficacy of this technique in the assessment of pancreatic texture as a predictor of postoperative pancreatic fistula (POPF). Methods: We conducted a comprehensive systematic literature research on PubMed, Google Scholar, Scopus, Web of Science, Embase and Cochrane Library Database using PRISMA framework guided by the words “intraoperative elastography” or “intraoperative elasticity imaging” or “intraoperative shear wave elastography” or “intraoperative strain elastography” and “pancreatic cancer” or “pancreatic neoplasm” or “pancreatic adenocarcinoma” or “pancreatic tumor” or “pancreatic fistula” or “postoperative pancreatic fistula” or “pancreatic leak”. Articles that were listed between 2000 and 2025 and written in the English language were screened for potentially relevant articles. The primary outcome was to evaluate the use of intraoperative elastography in differentiating between benign and malignant lesions of the pancreas. The second outcome was to assess the role of intraoperative elastography in the evaluation of pancreatic texture as a predictive factor for the occurrence of postoperative pancreatic fistula. Results: From a total of 17 publications, 2 scientific articles were considered relevant for the role of intraoperative elastography in differentiating benign from malignant pancreatic lesions, while 4 articles analyzed the role of intraoperative pancreatic elastography as a predictor of postoperative pancreatic fistula (POPF). Based on the results, detection of pancreatic cancer through intraoperative SWE is possible at cut-off values of 3 m/s and 28.7 kPa, and values of 2.2 m/s or less obtained after intraoperative elastography of the pancreas are considered an independent risk factor for POPF in pancreatic surgery. Reported cut-off values should, however, be interpreted as exploratory and should represent a starting point for further studies aimed at validating their clinical implementation. Conclusions: Intraoperative elastography can be a promising tool in pancreatic tumor characterization and could differentiate between benign and malignant pancreatic tumors and predict the risk of POPF, but further prospective studies are required before cut-off values can be routinely applied in clinical practice.