High-risk Pancreatic Anastomosis vs. Total Pancreatectomy after Pancreatoduodenectomy: Postoperative Outcomes and Quality of Life Analysis

OBJECTIVE To evaluate total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high-risk for postoperative pancreatic fistula (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, while 86 (63%) TP patients underwent C-TP. Postoperatively, the patients in the C-TP group exhibited lower rates of post-pancreatectomy 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 two 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 diabetes-specific QoL. CONCLUSIONS C-TP may be considered rather than HR-PD only in few selected cases and after adequate counselling.