Pancreatic Enucleation Linked to More Fistulas but Fewer Major Complications

A multicenter retrospective cohort study in JAMA Surgery compared enucleation with pancreatoduodenectomy for benign or low-grade malignant tumors of the pancreatic head or uncinate process. Researchers assessed 660 patients treated at four high-volume Chinese centers between 2015 and 2024, forming 217 propensity score–matched pairs. Median follow-up was 36 months. The primary endpoint was clinically relevant postoperative pancreatic fistula, defined as International Study Group on Pancreatic Surgery grade B or C.

In the matched cohort, fistulas occurred in 33.2% of enucleation patients versus 10.6% after pancreatoduodenectomy (adjusted odds ratio, 4.22; 95% CI, 2.47–7.21). However, enucleation was associated with fewer major complications (8.8% vs 17.1%; adjusted odds ratio, 0.37; 95% CI, 0.20–0.70), less delayed gastric emptying (4.6% vs 25.3%), and shorter median hospitalization (9 vs 15 days).

Overall, 551 patients completed quality-of-life assessment. Mean global health scores were higher after enucleation (77.4 vs 62.1), while new-onset diabetes was less frequent (7.8% vs 33.3%). Return to work was also more frequent among those assessed for that outcome (92.7% vs 72.0%). The major-complication advantage was greatest for tumors measuring 2.5 cm or less.

These findings suggest a trade-off between fistula risk and other perioperative and longer-term outcomes when considering parenchyma-sparing surgery. The retrospective design and residual tumor-size imbalance after matching limit causal interpretation; prospective confirmation is needed before drawing firm conclusions about comparative benefit.