The use and clinical outcome of total pancreatectomy in the United States, Germany, the Netherlands, and Sweden

Abstract

Background: Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries. Methods: Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014e2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo 3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume 40 pancreatoduodenectomies annually; data available for the Netherlands and Germany). Results: In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age 75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P ¼ .002), but not in Germany (9.8% vs 10.6%; P ¼ .733). Conclusion: Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.

Feasibility and outcome of spleen and vessel preserving total pancreatectomy (SVPTP) in pancreatic malignancies — a retrospective cohort study

“…Major complications (Clavien-Dindo ≥ IIIb) occurred in 23% within 90 days after surgery, and 90-day mortality was 5.4% in our series of 92 SVPTP patients. TP is known to be associated with high overall perioperative morbidity, with reported major complications of 25.5-34.5% and a mortality of 4-23% [28,[42][43][44][45][46][47]. In this regard, our own results are in agreement with the data in the literature on TP.…”

Contemporary indications for upfront total pancreatectomy

“…Third, the approach for performing TP was mainly open; however, there have recently been some studies which have reported cohorts of patients who underwent mini-invasive TP. Letenstein et al [30] have recently reported 1579 onestage TPs from 4 national registries: they were performed mainly using an open approach (93.5%), while laparoscopic and robotic approaches were performed rarely (2.1 and 1.3%, respectively). The mini-invasive approaches seemed to be reliable for performing TP in non-malignant diffuse diseases of the pancreas.…”

“…A pan-European prospective snapshot study [31] has recently found 5% in-hospital mortality after TP and identified predictors for mortality, including low-volume centres. Finally, a retrospective study including all the primary TPs of 4 registries (U.S., Germany, The Netherlands, and Sweden) showed that postoperative severe morbidity was 26.8% (423 cases out of 1579) and mortality ranged from 1.8% (U.S. registry, National Surgical Quality Improvement Program [NSQIP]) to 10.8% (Netherlands registry, Dutch Pancreatic Cancer Audit [DPCA]) [30]. The authors noted that the predictors of major morbidity were American Society of Anesthesiologists (ASA) score > 3, vascular resection, and periampullary cancer (P < 0.001), while postoperative mortality was mainly related to age > 75 years (P < 0.001) and vascular resection (P = 0.006).…”

Is it worthy to perform total pancreatectomy considering morbidity and mortality?: Experience from a high-volume single center

“…[10–12,14] There are also many cases of TP performed for unresolvable problems such as uncontrolled pain due to severe chronic pancreatitis. [14–17]…”

“…TP is required when tumors with malignant potential such as intraductal papillary mucinous neoplasm (IPMN) or neuroendocrine tumor (NET) are present multifocally throughout pancreas. [10–12,14] There are also many cases of TP performed for unresolvable problems such as uncontrolled pain due to severe chronic pancreatitis. [14–17]…”