Pancreatodudenectomy versus total pancreatectomy in patients at high risk of pancreatic fistula: A systematic review of the literature

Introduction: Postoperative pancreatic fistula (POPF) remains one of the most dreaded complications after pancreatoduodenectomy (PD), especially in patients with soft pancreatic parenchyma and a small main pancreatic duct. In this context, total pancreatectomy (TP) has been proposed to prevent the occurrence of POPF, although its metabolic consequences limit its widespread adoption. Objective: To compare the postoperative outcomes of PD and TP in patients at high risk of POPF, assessing morbidity, mortality, and metabolic consequences. Methods: A systematic literature search was conducted according to the PRISMA recommendations, including comparative studies of PD versus TP in a high-risk population. The criteria analyzed included morbidity, mortality, oncological outcomes and the occurrence of insulin-dependent diabetes mellites. Results: The available data suggest a reduction in overall morbidity and severe complications after TP, but at the cost of a high rate of postoperative diabetes mellites. Islet cell auto-transplantation (IAT) could mitigate these metabolic consequences, and has shown encouraging results on glycemia control and the preservation of residual insulin secretion. Conclusion: In patients at high risk of POPF, TP may be a pertinent alternative to PD, especially in complex anatomical or oncological situations. However, the metabolic benefit–risk balance needs to be carefully assessed, and strategies such as TP-IAT may improve functional outcomes. Additional randomized controlled trials are needed, including an accurate assessment of postoperative quality of life. © 2026 The Author(s)