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Categorization of Differing Types of Total Pancreatectomy

Educational Objective
To identify how the extent, complexity, and technical aspects of total pancreatectomy (TP) are relevant for postoperative outcomes.
1 Credit CME
Key Points

Question  Are differences in the extent, complexity, and technical aspects of total pancreatectomy (TP) relevant for postoperative outcomes after the procedure?

Findings  In a cohort study of 1451 patients who underwent TP, postoperative morbidity and mortality rates gradually and statistically significantly increased from (1) standard TP to (2) TP with venous resection, (3) TP with multivisceral resection, and (4) TP with arterial resection.

Meaning  The findings of this study suggest that TP comprises heterogeneous procedures; categorization of 4 different types of TP may be useful for better risk stratification and more accurate comparisons of future studies.

Abstract

Importance  Comparability of morbidity and mortality rates after total pancreatectomy (TP) reported by different surgical centers is limited. Procedure-specific differences, such as the extent of resection, including additional vascular or multivisceral resections, are rarely acknowledged when postoperative outcomes are reported.

Objectives  To evaluate postoperative outcomes after TP and categorize different types of TP based on the extent, complexity, and technical aspects of each procedure.

Design, Setting, and Participants  This single-center study included a retrospective cohort of 1451 patients who had undergone TP between October 1, 2001, and December 31, 2020. Each patient was assigned to 1 of the following 4 categories that reflect increasing levels of procedure-related difficulty: standard TP (type 1), TP with venous resection (type 2), TP with multivisceral resection (type 3), and TP with arterial resection (type 4). Postoperative outcomes among the groups were compared.

Main Outcomes and Measures  Categorization of different types of TP based on the procedure-related difficulty and differing postoperative outcomes.

Results  Of the 1451 patients who had undergone TP and were included in the analysis, 840 were men (57.9%); median age was 64.9 (IQR, 56.7-71.7) years. A total of 676 patients (46.6%) were assigned to type 1, 296 patients (20.4%) to type 2, 314 patients (21.6%) to type 3, and 165 patients (11.4%) to type 4 TP. A gradual increase in surgical morbidity was noted by TP type (type 1: 255 [37.7%], type 2: 137 [46.3%], type 3: 178 [56.7%], and type 4: 98 [59.4%]; P < .001), as was noted for median length of hospital stay (type 1: 14 [IQR, 10-19] days, type 2: 16 [IQR, 12-23] days, type 3: 17 [IQR, 13-29] days, and type 4: 18 [IQR, 13-30] days; P < .001), and 90-day mortality (type 1: 23 [3.4%], type 2: 17 [5.7%], type 3: 29 [9.2%], and type 4: 20 [12.1%]; P < .001). In the multivariable analysis, type 3 (TP with multivisceral resection) and type 4 (TP with arterial resection) were independently associated with an increased 90-day mortality rate.

Conclusions and Relevance  The findings of this study suggest there are significant differences in postoperative outcomes when the extent, complexity, and technical aspects of the procedure are considered. Classifying TP into 4 different categories may allow for better postoperative risk stratification as well as more accurate comparisons in future studies.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 30, 2021.

Published Online: November 17, 2021. doi:10.1001/jamasurg.2021.5834

Corresponding Author: Markus W. Büchler, MD, Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, D-69120 Heidelberg, Germany (markus.buechler@med.uni-heidelberg.de).

Author Contributions: Dr Büchler and Mr Hinz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Loos, Al-Saeedi, Hinz, Mehrabi, Strobel, Hackert, Büchler.

Acquisition, analysis, or interpretation of data: Loos, Al-Saeedi, Hinz, Mehrabi, Schneider, Berchtold, Müller-Stich, Schmidt, Kulu, Hoffmann, Strobel, Büchler.

Drafting of the manuscript: Loos, Mehrabi, Strobel, Hackert, Büchler.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Loos, Al-Saeedi, Hinz, Schneider, Schmidt.

Administrative, technical, or material support: Loos, Mehrabi, Schneider, Berchtold, Müller-Stich, Strobel, Hackert, Büchler.

Supervision: Loos, Mehrabi, Schmidt, Kulu, Hoffmann, Strobel, Hackert, Büchler.

Conflict of Interest Disclosures: None reported.

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