Total Pancreatectomy As an Alternative to Pancreaticojejunal Anastomosis in Very High Risk Patients for the Development of a Pancreatic Fistula after Pancreaticodudenectomy: Our Experience

Background: The Fistula Risk Score (FRS) for pancreaticoduodenectomy represent a validated tool to predict the onset of this treacherous complication. Although there is no agreement on the management of this peculiar subpopulation, total pancreatectomy is an option to be considered. Material & Methods: We considered 738 patients scheduled for a pancreaticoduodenectomy in our center between January 2010 and December 2018. Data were collected prospectively. 62 patients present a FRS ≥7. Major complication were considered as Clavien-Dindo ≥3. Continuous data are presented as median [IQR]. Islet autotrasplant after completion pancreatectomy is available in our institution as part of clinical studies for patients with preoperative normal glycemic control. Result(s): Of the 62 patients 35 where managed with pancreatico-jejunal anastomosis (GroupA); 18 with total pancreatectomy (GroupB1); 9 with total and islet autotransplant(GroupB2). In GroupB 70.4% underwent a spleen preserving procedure. 5.7% patients in GroupA,38.8% in GroupB1 were diabetic (p=0.038). Median age was 64.4[24.2] years GroupA; 73.1[10.1] GrupB1,67.5[12.2] GroupB2 (p=0,050). BMI was 24.85[6.6] GroupA 26.95[3.7] GroupB1 30.86[6.6] GroupB2 (p=0.014). 17,6% had an ASA score ≥3 in GroupA, 50% GroupB1, 33.3%, GroupB2 (p=0.079). 2 patients died 1 in GroupA an 1 in GroupB both to septic shock the second arising from a urinary tract infection. Major complication were 42.9% GroupA, 27.8% GroupB1, 22.2% GroupB2 (p=0.466). Reoperation rate was 17.1% GroupA, 11.1% GropB (p=0.090). Postoeprative length of stay was 15[9] GroupA 12[11] GroupB1 10[7] GroupB2 (p=0.501). Length of stay among total pancreatectomies was shorter in the spleen preserving 11[10] vs 14[9].In Group A Biochemical leak was 22.8%, pancreatic fistula B 40% C 8.5%. Readmission were observed only in Group A 25.7% (p:0.001). Conclusion(s): Completion pancreatectomy should be considered in high FRS patients, short term outcomes are good and islet autotrasplant offer promising scenarios for the long term. Patient’s characteristic and technical specific approaches had to be considered.