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

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 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% 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% 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% 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.