Enucleation vs Pancreatoduodenectomy for Benign and Low-Grade Pancreatic Head Tumors

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.