More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis

Abstract

Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection.

The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection

“… 23 and Hempel et al . 24 provide strong evidence that total pancreatectomy is a safe surgical option, which can offer benefits in selected patients with high-risk pancreatic anastomosis. Other possible management options for patients with a high risk of pancreatic fistula include a variety of anastomotic techniques such as prophylactic splinting of the main pancreatic duct or reconstruction via pancreaticogastrostomy 25 .…”

Systematic review and Meta-analysis of the Role of total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula

“…The literature search identified 1212 unique studies of which six studies fulfilled the eligibility criteria. [32][33][34][35][36][37] See Figure 1 for the PRISMA flow diagram. The six included studies comprised one multicenter randomized controlled trial, 33 two singlecenter observational matched studies, 35,36 and three single-center observational non-matched studies.…”

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data

“…In general, management options in patients with a known high risk of CR-POPF include different anastomotic techniques 34 , 35 , application of somatostatins 36 , 37 , adapted drain management 38 , 39 as well as intensified follow-up 40 , and changes in the overall surgical approach. In this context, recent studies provide evidence that in selected patients, primary total pancreatectomy, despite being associated with considerable postoperative morbidity 41 , 42 , could provide benefits over pancreatic head resection with a high-risk pancreatic anastomosis 43 – 46 . This option could be particularly viable in patients with preoperatively impaired glucose tolerance or when concomitant islet cell autotransplantation is an option 47 , 48 .…”