Total Pancreatectomy - Indications, Early Morbidity and Perioperative Strategy. Own Experience of 36 Consecutive Patients and Literature Review.

Background/ Aim: Total pancreatectomy (TP) is an uncommon type of pancreatic resection, even at high-volume centers. The indications of a TP are not fully defined, and the outcomes are controversial. The study aims to assess the frequency of use, indications, and early outcomes of TP in a contemporary consecutive series of 36 patients. Patients and The data of all consecutive elective TP performed by three experienced pancreatic surgeons between February 1, 2017, and December 31, 2024, were retrospectively extracted from a prospectively maintained electronic database of pancreatic resections. The data of patients requiring TP were analyzed for indications, surgical technique, and early outcomes. The patients were predominantly males (20 patients, 56%) with a median age of 67 years (range 44-76 years). Pancreatic ductal adenocarcinoma was the main indication (24 patients, 67%). The main reasons for a TP were multicentric lesions (14 patients, 39%), distal pancreas hypoplasia/ hypotrophy (8 patients, 22%), highrisk anastomoses (7 patients, 19%), and positive pancreatic margins (6 patients, 17%) following pancreaticoduodenectomy. Splenectomy was performed in 23 patients (64%), while venous and arterial resections were performed in 4 patients (11%) and two patients (6%), respectively. Overall and severe (i.e., grade 3 Dindo) morbidity rates were 83% and 25%, respectively, with a 90-day mortality of 6%. The primary sources of surgical morbidity were clinically relevant delayed gastric emptying (5 patients, 14%) and bile leak (4 patients, 11%). TP has rare and specific indications, including multicentric tumors, distal pancreas hypotrophy, positive pancreatic neck margins, and high-risk anastomosis after pancreaticoduodenectomy. In experienced hands, severe morbidity and mortality rates are acceptable for such a complex surgical procedure.