Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? —a matched-pairs analysis of 200 patients

Abstract

Background: Total pancreatectomy (TP) eliminates the risk of postoperative pancreatic fistula (POPF) and its associated secondary complications. Hence, it may theoretically offer advantages over pancreaticoduodenectomy (PD) regarding early postoperative outcome of patients with high-risk pancreatic remnant.Methods: Ninety-day mortality and morbidity of 100 TP vs. 100 PD for pancreatic head lesions were retrospectively compared. Groups were matched for pancreatic texture, pancreatic duct size, final histology, age, gender and surgeon. Only patients at high risk for POPF due to soft pancreatic texture and small pancreatic duct <3 mm were included.Results: Preoperatively, the TP-group was characterized by poorer general condition, more comorbidities and more pronounced obesity than the PD-group. Postoperatively, overall morbidity was lower after TP (63% vs. 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% vs. 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% vs. 5%) were the same. POPF was the most common complication after PD with 32%.Emergency completion pancreatectomy was necessary in 10% of PD with a significantly higher mortality compared to elective TP (50% vs. 7%, P=0.001).Conclusions: TP may reduce severe POPF-associated complications and prevent mortality related to emergency completion pancreatectomy in some elderly, obese and polymorbid patients with high-risk pancreatic remnant. Careful individual selection by an experienced pancreatic surgeon is mandatory.

Total pancreatectomy as an alternative to high-risk pancreatojejunostomy after pancreatoduodenectomy: a propensity score analysis on surgical outcome and quality of life

“…16 The national database from the American College of Surgeons revealed higher major morbidity and a doubled 30-day mortality rate (6% vs. 3%) after TP in comparison to PD. 39 In contrast, others demonstrated comparability 8,[13][14][15]18,40,41 in major morbidity (19-30% vs. 26-37%) 8,14,18,19 and perioperative mortality (0-7% vs. 0-5%) 8,[13][14][15]18,19,41 from which four studies matched both groups. [13][14][15]18 One single-center study compared TP versus PD with high-risk PJ (Fistula Risk Score 7-10), revealing no differences in major morbidity, 17 whereas Luu et al compared TP indicated for high-risk pancreatic remnant versus high-risk PD, demonstrating comparable major morbidity and mortality.…”

“…[13][14][15]18 One single-center study compared TP versus PD with high-risk PJ (Fistula Risk Score 7-10), revealing no differences in major morbidity, 17 whereas Luu et al compared TP indicated for high-risk pancreatic remnant versus high-risk PD, demonstrating comparable major morbidity and mortality. 18 Marchegiani et al compared intraoperatively converted PD to TP for any indication versus high-risk PD (alternative Fistula Risk Score), demonstrating a trend to significantly lower major morbidity (19% vs. 31%) after TP as consequence of lower rates of peripancreatic collections, intra-abdominal abscesses, sepsis, and haemorrhages among others. However, 90-day mortality rates were similar.…”

“…16 Three studies specified this comparison to PD with high-risk conditions, noticing the potential of TP to improve perioperative outcomes. [17][18][19] Quality of life (QoL) was investigated by only one of them, revealing comparable outcomes. 19 This study aims to investigate the clinical value of TP as an alternative to PD with a high-risk PJ to reduce short-term morbidity and mortality, thereby investigating the impact on long-term QoL.…”

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

“…Other strategies include disconnection followed by exteriorization and bridge stenting may be used in some scenarios. Revising pancreaticoenteric anastomosis and switching to other techniques is not feasible in most of these scenarios and should not be done (141)(142)(143)(144)(145)(146)(147)(148)(149)(150).…”

Reply to: Letter to the Editor: More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis, by Marchegiani, Giovanni et al.

“…Recently, three studies compared this particular group of high-risk PD procedures with TP in terms of surgical outcome, and reported mainly better results after TP. [3][4][5] Regarding quality of life, a retrospective analysis by Marchegiani et al 5 described comparable results after TP and high-risk PD. To prevent pancreoprivic diabetes or to preserve at least partial endogenous insulin secretion to mitigate the psychosocial aspects of diabetes or lifelong insulin therapy, intraportal islet autotransplantation should be also considered.…”