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Enucleation vs Pancreatoduodenectomy for Benign and Low-Grade Pancreatic Head Tumors
Zhengze Yao1, Yuanxing Gao1, Wei Wang2
1Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
Importance:
Pancreatic enucleation may offer a parenchyma-sparing alternative to pancreatoduodenectomy for benign and low-grade malignant pancreatic head tumors, but its perioperative risk-benefit profile relative to pancreatoduodenectomy remains incompletely defined.
Objective:
To compare short-term outcomes and long-term quality of life after enucleation vs pancreatoduodenectomy for benign and low-grade malignant tumors of the pancreatic head and uncinate process.
Design, Setting, And Participants:
This multicenter, retrospective cohort study assessed patients undergoing enucleation or pancreatoduodenectomy for benign or low-grade pancreatic head or uncinate process tumors at 4 high-volume Chinese centers (January 1, 2015, to December 31, 2024; median follow-up, 36 months) with 1:1 propensity score matching. Data analysis was performed from March to May 2026.
Exposure:
Pancreatic enucleation vs pancreatoduodenectomy.
Main Outcomes And Measures:
The primary end point was clinically relevant postoperative pancreatic fistula (CR-POPF; International Study Group on Pancreatic Surgery grade B or C). Secondary end points included major complications (Clavien-Dindo grade III or higher), delayed gastric emptying, length of stay, long-term quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire and 26-item Quality of Life Pancreatic Cancer Questionnaire), and new-onset diabetes. Tumor-to-main pancreatic duct distance was evaluated through stratified and multivariable analyses.
Results:
Of 660 patients (297 undergoing enucleation and 363 undergoing pancreatoduodenectomy; 355 [53.8%] female; median [IQR] age, 55.0 [41.0-65.0] years), 217 matched pairs were formed. CR-POPF was higher after enucleation (72 [33.2%] vs 23 [10.6%]; adjusted odds ratio, 4.22; 95% CI, 2.47-7.21; P < .001). Major complications were lower (19 [8.8%] vs 37 [17.1%]; adjusted odds ratio, 0.37; 95% CI, 0.20-0.70; P = .002) as was delayed gastric emptying (10 [4.6%] vs 55 [25.3%]; P < .001). Median (IQR) stay was 9 (6-14) vs 15 (11-22) days (P < .001). A total of 551 patients (83.5%) completed quality-of-life assessment; enucleation was associated with higher global health status (mean [SD] scores, 77.4 [13.7] vs 62.1 [18.0]; P < .001), lower new-onset diabetes (7.8% [20 of 257] vs 33.3% [98 of 294]; P < .001), and higher return to work (92.7% [191 of 206] vs 72.0% [121 of 168]; P < .001). Enucleation's complication advantage was greatest for tumors 2.5 cm or smaller (5.8% [6 of 104 patients] vs 26.2% [17 of 65 patients]; P for interaction = .01).
Conclusions And Relevance:
In this multicenter cohort study, enucleation for benign and low-grade pancreatic head tumors was associated with higher CR-POPF than pancreatoduodenectomy but fewer major complications, less delayed gastric emptying, shorter hospitalization, and superior long-term quality of life. These findings support enucleation as a viable option when technically feasible, particularly for tumors 2.5 cm or smaller; residual tumor size imbalance after matching warrants prospective confirmation.
