Initiation and Completion of Adjuvant Chemotherapy After Total Versus Partial Pancreaticoduodenectomy for Pancreatic Cancer.

backgroundPartial pancreaticoduodenectomy (PD) followed by adjuvant chemotherapy (AC) is standard treatment for resectable pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. Total pancreatectomy (TP) has historically been reserved for extensive tumors or salvage procedures due to concerns about morbidity and quality of life (QoL). However, recent evidence shows comparable perioperative outcomes and QoL between TP and PD. The authors hypothesized that avoiding postoperative pancreatic fistula TP would achieve AC initiation and completion rates similar to those for PD, even in more complex patients.

methodsThis study retrospectively analysed all patients who underwent TP or PD for PDAC at the authors' center between 2014 and 2021. Rates, timing, and completion of AC were compared. The decision for TP versus PD was based on patient and intraoperative factors at the discretion of the surgeon.

resultsOf 263 included patients, 74 underwent TP and 189 underwent PD. Total pancreatectomy was performed mainly for repetitive positive resection margins or splenic vessel involvement (59 %). The TP patients had more comorbidities (liver disease, 16.2 % vs 5.8 % p = 0.013; diabetes, 40.5 % vs 24.9 % p = 0.016), longer surgeries (7.2 vs 6 h; p = 0.001), more vascular reconstructions (77 % vs 50.8 %; p = 0.001), and greater blood loss (1200 vs 600 ml; p = 0.001). Despite these factors, morbidity and mortality were comparable. The two groups did not differ in rates of AC initiation (66 % vs 76 %; p = 0.156), completion (69.4 % vs 74.1 %; p = 0.578), and timing (median, 7 weeks in both groups; p = 0.533).

conclusionDespite higher surgical complexity, AC initiation and completion rates after TP were comparable with those after PD. With modern diabetes management, TP represents a valid surgical option for selected high-risk patients without compromising oncologic treatment.