High-risk Pancreatic Anastomosis Versus Total Pancreatectomy After Pancreatoduodenectomy

Abstract

Objective: To evaluate TP as an alternative to PD in patients at high-risk for popf. Background: Outcomes of high-risk PD (HR-PD) and TP have never been compared. Methods: All patients who underwent PD or TP between July 2017 and December 2019 were identified. HR-PD was defined according to the alternative fistula risk score. Postoperative outcomes (primary endpoint), pancreatic insufficiency, and quality of life after 12 months of follow-up (QoL) were compared between HR-PD or planned PD intraoperatively converted to TP (C-TP). Results: A total of 566 patients underwent PD and 136 underwent TP during the study period. One hundred one (18%) PD patients underwent HR-PD, whereas 86 (63%) TP patients underwent C-TP. Postoperatively, the patients in the C-TP group exhibited lower rates of postpancreatectomy hemorrhage (15% vs 28%), delayed gastric emptying (16% vs 34%), sepsis (10% vs 31%), and Clavien-Dindo ≥3 morbidity (19% vs 31%) and had shorter median lengths of hospital stay (10 vs 21 days) (all P < 0.05). The rate of POPF in the HR-PD group was 39%. Mortality was comparable between the 2 groups (3% vs 4%). Although general, cancer- and pancreas-specific QoL were comparable between the HR-PD and C-TP groups, endocrine and exocrine insufficiency occurred in all the C-TP patients, compared to only 13% and 63% of the HR-PD patients, respectively, and C-TP patients had worse diabetesspecific QoL. Conclusions: C-TP may be considered rather than HR-PD only in few selected cases and after adequate counseling.

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.…”

“…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.…”

State-of-the-art surgical treatment of IPMNs

“…TP is indicated in cases of diffuse MPD involvement, multifocal disease in patients with family history positive for PDAC, and persistent HGD at the resection margin because the established risk for recurrence and/or cancer in these patients makes the morbidity of TP more acceptable [52]. Moreover, recent studies have reported improved perioperative outcomes and postoperative quality of life (QoL) after TP, presumably due to centralization at high-volume centers and development of long-acting insulin and modern pancreatic enzyme preparations [53][54][55][56][57].…”

Total pancreatectomy and pancreatic fistula: friend or foe?

“…Unfortunately, data exploring this topic are sparse and come solely from recently published studies [ 8 , 16 ]. Far from advocating the systematic use of TP in high-risk scenarios, we think that it may be considered as an alternative to perform a high-risk pancreatic anastomosis in highly selected patients for whom the short-term benefits in the postoperative setting may overcome the disadvantages due to the complete absence of residual pancreatic function.…”

“…In this perspective, the encouraging postoperative outcomes of total pancreatectomy (TP) reported at high-volume centers in recent years [ 6 , 7 ] have led the authors questioning whether the burden of complications related to a high-risk pancreatic anastomosis could justify the use of TP as an alternative strategy in selected patients to avoid the occurrence of POPF [ 8 ].…”