This international multicenter study, sought to establish reference values for surgical outcomes following total pancreatectomy (TP). TP is performed for advanced pancreatic cancer or multifocal tumors, or to mitigate the risk of postoperative pancreatic fistula in selected patients. Despite its potential benefits, TP remains a high‑risk procedure associated with significant morbidity and mortality.
Data were collected from 994 patients across 25 expert centers worldwide between 2017 and 2023. A low‑risk TP (LR‑TP) cohort of 333 patients was defined as those without major comorbidities and without vascular resections. Twenty reference values were derived, including blood loss (≤1000 mL), operative time (≤456 minutes), major complication rate (≤37%), 90‑day mortality (<6%), and number of retrieved lymph nodes (≥29). For patients with pancreatic ductal adenocarcinoma, oncologic benchmarks included R1 resection rate (≤41.7%) and one‑year overall survival (≥68.4%).
Further, comparisons revealed that outcomes for TP with vascular resections or TP performed due to high‑risk anastomosis exceeded LR‑TP cutoffs, with markedly higher complication rates, failure to rescue, and 90‑day mortality (11% vs ≤6%). When compared with low‑risk pancreatoduodenectomy, LR‑TP demonstrated threefold higher postoperative mortality (≤6% vs ≤2%). Predictors of poor outcomes included longer operative time, intraoperative decision to perform TP, patient age, and need for transfusion.
The study concludes that even in specialized centers, TP carries substantially higher risks than pancreatoduodenectomy, particularly when vascular resections are involved. The reference values provided offer a framework for benchmarking, quality control, and international comparison of outcomes in pancreatic surgery. Importantly, the findings caution against liberal use of TP for high‑risk anastomosis, given its relevant high mortality and failure to rescue rate.
Interview with Prof. Dr. med. Beat P. Müller, Prof. Dr. med. Adrian Billeter, PD Dr. med. Philip C. Müller (Basel)
What inspired you to conduct this study?
The primary objective of our academic abdominal surgery unit is to foster international, collaborative research on clinically relevant topics. Given our strong clinical focus on advanced pancreatic surgery and the absence of contemporary reference values for total pancreatectomy, we used our international network to address several important questions related to total pancreatectomy (see below).
Were there any unexpected findings?
In technically challenging pancreatoduodenectomies—such as cases involving a small duct and soft pancreatic texture—total pancreatectomy is often proposed as an alternative to avoid a high-risk anastomosis. In these patients with total pancreatectomy to avoid high-risk pancreatic anastomosis, postoperative mortality was high and comparable to that observed in patients undergoing total pancreatectomy with concomitant vascular resections (>10%). This pivotal finding stands in contrast to the prevailing tendency to favor total pancreatectomy in high-risk anastomotic settings. Accordingly, these data suggest that every reasonable effort should be made to perform a pancreatic anastomosis, even in high-risk patients.
What is the direct impact on the surgeon’s work?
First, despite being performed in high-volume international expert centers with advanced intraoperative and postoperative management, total pancreatectomy remains a high-risk procedure with substantial postoperative mortality. Second, in the context of increasing use of neoadjuvant therapy, total pancreatectomy combined with vascular resection is being performed more frequently for locally advanced tumors. This subgroup is at particularly high risk for major complications and postoperative death. These findings have important implications for perioperative decision-making and preoperative patient counseling. However, some data also suggest that these patients experience a strong oncologic benefit. We are currently further investigating this point.
What is your learning point from this project?
Clinical practice and especially strategies with good intentions that are proposed such as total pancreatectomy for high-risk anastomosis, must be carefully evaluated in large cohorts before they can be widely recommended. This study clearly shows the value of evaluating practice based well-intended assumptions.
Are there any subsequent projects planned?
During the course of this analysis, several additional questions emerged. The international collaborative represents a unique opportunity to address important and clinically relevant questions in pancreatic surgery that would be difficult to answer within a smaller, single-center cohort. First, we aim to evaluate the oncologic outcomes of total pancreatectomy compared with different forms of formal pancreatectomy. This question is particularly relevant as expert centers worldwide increasingly pursue resection of locally advanced tumors. Second, we seek to investigate in greater detail the underlying reasons for the high postoperative mortality associated with total pancreatectomy. In pancreatoduodenectomy, distinct clusters of mortality have been identified; we intend to determine whether similar patterns can be observed following total pancreatectomy.
