Imaging Pearls ❯ Pancreas ❯ 3D Imaging in Staging
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- Introduction: Three-dimensional (3D) reconstruction transforms cross-sectional medical images into interactive anatomical models, interpretable on an LCD screen, in augmented reality or via 3D printing. Although certain benefits have been established in liver surgery, its use in pancreatic surgery remains limited. This update outlines the applications of 3D visualization in pancreatic surgery, ranging from surgical planning to teaching.
Results: The analysis of these studies suggests that 3D reconstruction, in comparison to cross-sectional imaging, could improve preoperative evaluation, by facilitating the detection of anatomical variations, the assessment of resection margins, and the prediction of morbidity and mortality according to tumor volume and residual pancreatic parenchyma. 3D imaging could also improve intraoperative safety, with some series reporting a 50% reduction of blood loss and a 25% reduction in operating time. 3D reconstruction is also a promising tool for teaching surgical anatomy, particularly through 3D printing.
Conclusion: 3D reconstruction could improve outcomes of pancreatic surgery but requires robust comparative studies before becoming a standard evidence-based practice.
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al.
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011 - Conversely, the use of 3D reconstructions in pancreatic surgery is still limited, and the scientific literature on the subject remains scarce. However, pancreatic surgery is also notorious for its complexity: resectability is determined by anatomic vascular relationships, the risk of bleeding is high,postoperative complications are frequent, and the prognosis of pancreatic disease, particularly malignancies, remains generally bleak with a low 5-year survival rate. These characteristics make 3D reconstructions a particularly relevant field, both to improve surgical planning and anticipate technical difficulties as well as to refine resectability criteria.
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al. Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011 - 3D reconstruction could offer a substantial advantage over 2D imaging in the preoperative evaluation of resection margins, especially that of arterial resection, which isa key element in the surgical strategy of pancreatic tumor surgery. In a retrospective study of 105 patients, Griser et al. showed that the diagnostic performance (area under the curve of the receiver-operator characteristic curve) forthe assessment of arterial invasion was statistically significantly better than that of 2D. These results were confirmed by Fang et al., who, thanks to an improvement in sensitivity, specificity, and positive and negative predictive values provided by 3D reconstruction, proposed a new classification of tumor resectability based on these three-dimensional models. One of the hypotheses put forward toexplain this superiority is that 2D imaging tends to under-estimate the true tumor volume and that there is acorrelation between tumor volume, TNM stage and the risk of recurrence.
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al.
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011 
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al.
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011- 3D reconstruction of the pancreas is currently based on 2D images (CT or MRI), the quality of which depends on the thickness of the slices and the stability of the patient. Man-ual or semi-automated reconstructions are time-consuming and require expertise. Outsourcing processing by specialized private companies or the development of automated tools,particularly through deep learning, could improve the accuracy and reduce processing time. Medico-economic studies comparing the different solutions should be conducted to move from a frenzy for innovation to evidence-based practices.
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al.
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011 - To date, the traditional open laparotomy approach remains preferable in pancreatic surgery in many settings, particularly in the case of a locally advanced tumor or a complex surgical procedure. Regarding PD, which isthe most common intervention, randomized trials comparing laparoscopic versus the open route have not formally demonstrated a clear benefit of the minimally invasive approach in terms of morbidity and mortality or oncologi-cal outcomes . Similarly, the robotic approach, although innovative, still needs to prove itself in high-level methodology studies before being generalized.In this context, AR could represent a real game-changer for minimally invasive approaches. Indeed, the possibility of projecting 3D reconstructions in real time directly on the screen during laparoscopic or robotic-assisted surgery could compensate for the absence of tactile and visual cues that are specific to open surgery. This technological integration, which is difficult to transpose to conventional surgery,would strengthen the safety and precision of gestures in minimally invasive procedures.
Value of 3D reconstructions in pancreatic surgery: Current status
E. Roussel, J. Pinson, L. Duhamel et al.
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2025.09.011
"The technique is also valuable in providing a time-efficient method to review pertinent findings with clinicians."
Evaluation of Periampullary Pathology With CT Volumetric Oblique Coronal Reformations
Pham DT et al.
DOI:10.2214/AJR.08.2069"Volumetric oblique coronal reformations are a useful noninvasive method to provide diagnostic information about periampullary abnormalities as well as show secondary features important for local staging and management. The technique is also valuable in providing a time-efficient method to review pertinent findings with clinicians."
Evaluation of Periampullary Pathology With CT Volumetric Oblique Coronal Reformations
Pham DT et al.
DOI:10.2214/AJR.08.2069- "A combination of pancreatic parenchymal phase and PVP imaging is necessary and efficient for the assessment of pancreatic adenocarcinoma. The addition of coronal and sagittal MPR images increased the performance of MDCT, especially in the evaluation of local extension."
MDCT of Pancreatic Adenocarcinoma: Optimal Imaging Phases and Multiplanar Reformatted Imaging
Ichikawa T et al.
AJR 2006; 187:1513-1520
- "The addition of coronal and sagittal MPR images to the MDCT protocol increases the sensitivity of MDCT and improves its agreement with surgical findings regarding local staging factors."
MDCT of Pancreatic Adenocarcinoma: Optimal Imaging Phases and Multiplanar Reformatted Imaging
Ichikawa T et al.
AJR 2006; 187:1513-1520
- "Pancreas protocol CT imaging appears to be a better predictor of resectability compared with EUS. EUS accuracy is affected by the presence of biliary stents."
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
- "Venous involvement >180° and arterial involvement >90° by CT had a 100% positive predictive value for failure to achieve R0 resection."
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
(R0 is margin negative)
- "Several reports concluded that local extension of pancreatic cancer and invasion of adjacent vascular structures could be well depicted with helical CT, with the main limitations of this technique for preoperative staging being a difficulty in revealing unsuspected liver metastases and a low rate of revealing lymph node metastases."
Diagnosis of pancreatic cancer
Miura F et al.
HPB 2006; 8:337-342
- Role of 3D Imaging in the Evaluation of Pancreatic Cancer
- House et al Gastrointestinal Surg 2004;8:280-288.
- Among patients with periampullary cancer, the extent of tumor burden involving the pancreas and peripancreatic tissues was accurately depicted by 3D CT in 93% of patients
- 3D CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels
- Resectability rate/margin negative rate - Periampullary 98%/ 85%
- Role of 3D Imaging in the Evaluation of Pancreatic Cancer
- Raptolpoulos AJR 1997;168:971-977
- SDCT
- Found that 3D imaging of the peripancreatic vasculature was more accurate than axial images alone in revealing resectable disease
- By adding 3D imaging of the vessels, the negative predictive value of a resectable tumor was 96% compared to 70% for axial images alone.
- Role of 3D Imaging in the Evaluation of Pancreatic Cancer
- Raptolpoulos AJR 1997;168:971-977
- SDCT
- Found that 3D imaging of the peripancreatic vasculature was more accurate than axial images alone in revealing resectable disease
- By adding 3D imaging of the vessels, the negative predictive value of a resectable tumor was 96% compared to 70% for axial images alone.
- Role of 3D Imaging in the Evaluation of Pancreatic Cancer
- House et al Gastrointestinal Surg 2004;8:280-288.
- Among patients with periampullary cancer, the extent of tumor burden involving the pancreas and peripancreatic tissues was accurately depicted by 3D CT in 93% of patients
- 3D CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels
- Resectability rate/margin negative rate
- Periampullary 98%/ 85%
- "Multidetector row CT with 3-dimensional volume rendering allows for accurate delineation of the portal venous system and collaterals that develop in cases of portal hypertension.Whereas the direction of blood flow cannot be determined on axial images the pattern of collateral circulation that develops can predict the flow direction to bypass a point of obstruction along the portal venous system."
Patterns of Collateral Pathways in Extrahepatic Portal Hypertension as Demonstrated by Multidetector Row Computed Tomography and Advanced Image Processing
Kamel IR, Lawler LP, Corl FM, Fishman EK J Comput Assist Tomogr 2004;28:469-477
- "Multidetector row CT with 3-dimensional volume rendering allows for accurate delineation of the portal venous system and collaterals that develop in cases of portal hypertension."
Patterns of Collateral Pathways in Extrahepatic Portal Hypertension as Demonstrated by Multidetector Row Computed Tomography and Advanced Image Processing
Kamel IR, Lawler LP, Corl FM, Fishman EK
J Comput Assist Tomogr 2004;28:469-477
- "Among the patients with periampullary cancer, the extent of local tumor burden involving the pancreas and peripancreatic tissues was accurately depicted by 3D-CT in 93% of the patients. 3D-CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels. Preoperative 3D-CT accurately predicted periampullary cancer resectability and a margin-negative resection in 98% and 86% of patients, respectively."
Predicting resectability of periampullary cancer with three-dimensional computed tomography
House MG et al
J Gastrointest Surg. 2004 Mar-Apr;8(3):280-8.
- What post processing tools are helpful for evaluation of the pancreas?
- Multiplanar reconstruction
- Curved planar reformations
- 3D volume rendering
- Maximum intensity projection (MIP)
- "Curved planar reformations are equivalent to transverse images in the detection of pancreatic tumors and determination of surgical resectability."
Local Staging of Pancreatic Carcinoma with Multidetector Row CT: Use of Curved Planar Reformations-Initial Experience
Prokesch RW et al.
Radiology 2002; 225:759-765