Transection level matters: A prospective study on pancreatic fistula risk after left pancreatectomy
In brief
Pancreatic neck-to-tail resections had 32% fistula rates, versus 17% after standard resection
In a 971-patient study, clinically relevant fistulas occurred in 31.9% of patients after neck-to-tail resections, compared with 17.3% after standard body-tail resection; tail resections had a 27.8% rate. The associations persisted after propensity matching but weakened after accounting for pancreatic thickness and stump management, suggesting transection level also reflects technical complexity.
- Journal
- Surgery (Q1)
- Published
- 31 August 2026
- Study design
- Cohort / observational study
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Angelica Nepi, Matteo De Pastena, Gabriella Lionetto, Salvatore Paiella, Naomi Ingaglio, Valeria Casule, et al.
- PMID
- 42854299
- DOI
- 10.1016/j.surg.2026.110580
Why clinicians should know about it
- Picked for Surgery (paper of the day, 13 October 2026): Transection level impacts pancreatic fistula risk
Abstract
BACKGROUND: Postoperative pancreatic fistula remains the main cause of morbidity after left pancreatectomy, but the impact of pancreatic transection level on postoperative outcomes remains debated. METHODS: We retrospectively analyzed a prospectively maintained single-center database of consecutive patients undergoing left pancreatectomy for malignant, premalignant, or benign disease between 2016 and 2024. Transection level was classified as standard pancreatic body-tail resection, pancreatic neck-body-tail resection/extended pancreatic neck-body-tail resection, or pancreatic tail resection. The primary end point was clinically relevant postoperative pancreatic fistula. Secondary end points included postpancreatectomy fluid collections, organ/space surgical site infection, postpancreatectomy hemorrhage, major complications, mortality, and endocrine/exocrine insufficiency. Associations were assessed using multivariable logistic regression, propensity-score matching, sensitivity analyses, and concordance index comparison. RESULTS: Among 971 patients, transection was pancreatic body-tail resection in 661 (68.1%), pancreatic neck-body-tail resection/extended pancreatic neck-body-tail resection in 116 (11.9%), and pancreatic tail resection in 194 (20.0%). Postoperative pancreatic fistula occurred in 205 patients (21.1%) and was more frequent after nonstandard transections (pancreatic body-tail resection, 17.3%; pancreatic neck-body-tail resection/extended pancreatic neck-body-tail resection, 31.9%; pancreatic tail resection, 27.8%; P < .001). In multivariable analysis, pancreatic neck-body-tail resection/extended pancreatic neck-body-tail resection (odds ratio, 1.87; 95% confidence interval, 1.05-3.28) and pancreatic tail resection (odds ratio, 2.07; 95% confidence interval, 1.19-3.58) were associated with postoperative pancreatic fistula versus pancreatic body-tail resection. The association persisted after propensity-score matching but was attenuated after adjustment for pancreatic thickness and stump management. Pancreatic neck-body-tail resection/extended pancreatic neck-body-tail resection was associated with postpancreatectomy hemorrhage, and both nonstandard transections were associated with organ/space surgical site infection. CONCLUSION: Transection level was associated with postoperative pancreatic fistula, organ/space surgical site infection, and postpancreatectomy hemorrhage after left pancreatectomy, supporting its role as an intraoperative marker of anatomic and technical complexity.
Abstract as published, via PubMed.
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