A multicenter retrospective cohort study published by Yao et al in JAMA Surgery found that although pancreatic enucleation was associated with a higher rate of clinically relevant postoperative pancreatic fistula than pancreatoduodenectomy, it was linked to fewer major complications, less delayed gastric emptying, shorter hospital stays, and better long-term quality of life among patients with benign or low-grade pancreatic head tumors.
“Enucleation should be considered a viable option for benign and low-grade pancreatic head tumors when technically feasible, particularly for tumors [measuring] 2.5 cm or smaller,” the investigators commented.
Study Details
The investigators focused on 660 patients who underwent pancreatic enucleation (n = 297) or pancreatoduodenectomy (n = 363) for benign or low-grade pancreatic head or uncinate process tumors at four high-volume Chinese centers. The median age was 55 years, 53.8% were female, and 217 matched pairs were identified through 1:1 propensity score matching. Follow-up data were provided for a median of 36 months.
The primary endpoint was clinically relevant postoperative pancreatic fistula, defined as grade B or C according to International Study Group on Pancreatic Surgery criteria. Secondary endpoints included major complications (Clavien-Dindo grade ≥ III), delayed gastric emptying, hospital length of stay, long-term quality of life, and new-onset diabetes. Stratified and multivariable analyses were also conducted to assess the distance between the tumor and the main pancreatic duct.
Key Findings
Clinically relevant postoperative pancreatic fistula was more common following enucleation than pancreatoduodenectomy (33.2% vs 10.6%; adjusted odds ratio [OR] = 4.22; P < .001). However, enucleation was found to be associated with lower rates of major complications (8.8% vs 17.1%; adjusted OR = 0.37; P = .002) and delayed gastric emptying (4.6% vs 25.3%; P < .001), as well as a shorter median hospital stay (9 vs 15 days; P < .001).
Among the 551 patients (83.5%) who completed quality-of-life assessments, those who underwent enucleation reported higher mean global health status scores (77.4 vs 62.1; P < .001), had lower rates of new-onset diabetes (7.8% vs 33.3%; P < .001), and were more likely to return to work (92.7% vs 72.0%; P < .001).
According to the investigators, the reduction in major complications associated with enucleation was most pronounced among patients with tumors measuring 2.5 cm or smaller (5.8% vs 26.2%; P for interaction = .01).
“This study found that enucleation for benign and low-grade malignant tumors of the pancreatic head and uncinate process was associated with higher [rates of clinically relevant postoperative pancreatic fistula] than pancreatoduodenectomy (predominantly grade B), but significantly fewer major complications, markedly lower rates of [delayed gastric emptying], and shorter hospitalization,” the investigators concluded.
They continued, “Stratified analyses supported enucleation even for tumors close to the [main pancreatic duct] and identified 2.5 cm as the size threshold for greatest complication benefit. Long-term follow-up demonstrated superior quality of life, lower new-onset diabetes, and higher return-to-work rates after enucleation.”
Prospective studies incorporating systematic assessment of main pancreatic duct distance and longitudinal patient-reported outcomes are needed to validate these findings.
Rong Liu, MD, and Qu Liu, MD, of First Medical Center of Chinese PLA General Hospital, Beijing, are the corresponding authors of the article in JAMA Surgery.
DISCLOSURE: The study authors reported no conflicts of interest.
