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

Abstract

Background: Total pancreatectomy (TP) is mentioned as alternative to pancreatoduodenectomy (PD) with high-risk pancreatojejunostomy (PJ) to avoid severe pancreatic fistula-related complications, but its benefit is controversial and comparative studies are scarce.Methods: Cross-sectional single-center study among patients after PD with high-risk PJ versus patients after single-stage elective TP for any indication (2015-2017), using propensity scores to evaluate surgical outcomes and long-term quality of life (QoL) in three risk strata. EORTC QLQ-C30 and EQ-5D-5L were used for QoL assessment.Results: Overall, 77 patients after TP (68.8%) and 102 patients after high-risk PD (34.5%) were included. Major morbidity (29.9% vs. 41.2%; p = 0.119) and 90-day mortality (5.2% vs. 8.8%; p = 0.354) did not differ significantly between TP and high-risk PD. Interventions for intra-abdominal fluid collections (9.1% vs. 23.5%, p = 0.011) and postpancreatectomy haemorrhage (6.5% vs. 18.6%; p = 0.018) were more often required after high-risk PD, but these differences did not remain after stratification. QoL was comparable after TP and high-risk PD (75% vs. 83%; p = 0.720), even after stratification.Conclusions: TP seems not to be inferior to high-risk PD regarding surgical outcomes and QoL. TP could be considered as an alternative to a very high-risk PD, but reluctance persists since TP does not appear to reduce mortality. Q4

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.…”

“…Patients with vascular resection and reconstruction might be particularly at risk of PPH in case of POPF. Stoop et al demonstrated in a recent study that TP even in the consequence of type III DM (pancreoprivic diabetes mellitus) is [5.4] equivalent to PD in long-term surgical outcome and quality of life [28].…”

Applicability of the surgical risk calculator by the American College of Surgeons in the setting of German patients undergoing complete pancreatectomy: multicentre study using data from the StuDoQ|Pancreas registry

“…Given an expected occurrence rate of 4 per cent for an outcome this would require a data set of at least 2500 patients. As total pancreatectomy has a high rate of morbidity, it was hoped to be able to produce valid results using a smaller sample 27 . As requests for publication of the detailed model of the ACS SRC have been rejected, automated external validation remains impossible 21 .…”

Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy

“…Despite its discriminative value (0.77 [95% confidence interval 0.70–0.83]), the high-risk group had ‘only’ a risk of 6.6% to develop a POPF grade C, suggesting that substantial uncertainty remains [ 5 ]. The major challenge to predict POPF grade C and the associated high mortality could be an argument for a prophylactic total pancreatectomy during index surgery in the presence of very high–risk conditions and carefully selected patients [ 40 , 41 ]. Hereby, simplified pre- and intraoperative predictors can support patient selection and counselling [ 42 , 43 ].…”