More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis
- Open Access
- 19.03.2022
- Pancreatic Tumors
Erschienen in:
Dear Editor,
We read with great interest this paper from Hempel et al. that compared oncological and postoperative outcomes of pancreaticoduodenectomy (PD) and primary total pancreatectomy (TP) in patients with periampullary cancer after matching for age, sex, tumor, nodal and resection status.1 No differences were found in the median overall and progression free survival, and in completion of adjuvant therapy. Moreover, postoperative morbidity and mortality were similar in the two groups. They conclude that “especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, primary TP may provide a safe treatment alternative to pancreatic head resection.”
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The postoperative outcomes of TP recently gained great attention in the scientific literature, unlike its oncological counterparts.2‐6 The authors should be commended for highlighting this crucial aspect, especially with regards to the access to adjuvant chemotherapy after resection.
However, we have some comments. Despite accurate matching, patients in the TP group underwent more extended resections, with higher rates of vascular resections and more frequently after neoadjuvant chemotherapy. As recently reacknowledged by the Heidelberg group, TP has a wide spectrum of indications and a significant heterogeneity in surgical complexity, underlining the need for a better stratification according to intraoperative parameters.6
More importantly, risk stratification for postoperative pancreatic fistula (POPF) was not considered in the matched analysis. We therefore feel that a crucial aspect is missing. If not indicated for oncological reasons, TP cannot be considered as an alternative in all patients undergoing PD, but only once an extremely high-risk of POPF is present. Moreover, although comparable postoperative and oncological outcomes where hereby found, the life-long sequelae in terms of pancreatic insufficiency are a fundamental variable in the equation and cannot be ignored.
During the past year, three studies compared the surgical outcomes of high-risk PD and TP, often revealing better results after TP.7‐9 A recent retrospective analysis also compared postoperative quality of life (QoL) in the two groups. Nonspecific, cancer-specific, and pancreas-specific QoL was similar after TP and high-risk PD. However, the psychosocial impact of diabetes, the need for insulin therapy, and the severity of exocrine insufficiency were all significantly higher after TP, confirming the severity of its life-long burden related to a complete removal of pancreatic parenchyma.9
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In conclusion, we acknowledge the importance of the present contribution. Thanks to a better understanding of the oncological aspects of TP (such as the access to adjuvant chemotherapy), another important step was done toward considering it “more” for some patients. The very heart of the matter lies in the proper selection of the population in which TP can actually be a game-changer. Namely, those patients in which avoiding a POPF and its related sequalae can overcome the drawbacks of a life-long diabetes and exocrine insufficiency. Hopefully, a randomized, controlled trial that is currently ongoing will help to identify this very selected but relevant population.
DISCLOSURE
The authors declare no conflicts of interest.
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