Low incidence of pancreatic fistula and well-preserved endocrine function with non-reconstructed small remnant pancreas after pancreaticoduodenectomy.

Aim: Pancreatic reconstruction after pancreaticoduodenectomy (PD) that leaves a small remnant pancreas is often difficult. Pancreatic fistula is a major complication after PD, and fistulas are rare in patients with hard pancreas. However, the clinical impact of non-reconstructed small remnant after PD with hard pancreas is unknown. Methods: We included all patients who underwent PD for pancreatic tumor without pancreatic reconstruction in two institutions supervised by one surgeon between January 2004 and March 2021. Their short- or long-term outcome after surgery was retrospectively analyzed. Results: PD was performed in 774 patients, of whom 16 patients were without reconstruction (2.1%) with negative margins at the pancreatic stump. Pancreatic transection was performed above or to the left of the superior mesenteric artery, with a median remnant pancreas length of 3.7 cm (range, 1.3-10.0). A major complication (≥ Clavien-Dindo Grade IIIa) occurred in one patient (6%). Fistula of grade B occurred in one patient (6%). After a median follow-up of 44 months (95%CI, 10.6-77.3), insulin administration was unnecessary in 11 patients. Conclusion: The preservation of a small pancreatic remnant without reconstruction after PD can be performed safely and may enable the keeping of pancreatic endocrine function for some selected patients with hard pancreas.