Enucleation for small pancreatic head tumours: more fistulas, fewer major complications than a Whipple

Design

Multicentre retrospective cohort with 1:1 propensity matching

Population

434 matched patients with benign or low-grade pancreatic head or uncinate tumours at four Chinese centres

Primary outcome

Clinically relevant postoperative pancreatic fistula (ISGPS grade B/C)

Effect

33.2% vs 10.6% (aOR 4.22, 95% CI 2.47-7.21); major complications 8.8% vs 17.1% (aOR 0.37)

Four high-volume Chinese centres compared enucleation with pancreatoduodenectomy for benign or low-grade tumours of the pancreatic head and uncinate process, operated on between 2015 and 2024 (JAMA Surgery, 30 September 2026). After propensity matching, 217 pairs were analysed, with median follow-up of 36 months.

Clinically relevant postoperative pancreatic fistula (ISGPS grade B or C) was three times as common after enucleation (33.2% vs 10.6%; adjusted OR 4.22, 95% CI 2.47-7.21). Yet Clavien-Dindo grade III or worse complications were lower (8.8% vs 17.1%; adjusted OR 0.37, 0.20-0.70), delayed gastric emptying was far less frequent (4.6% vs 25.3%) and median stay was shorter (9 vs 15 days). Enucleation was associated with better global health scores, less new-onset diabetes (7.8% vs 33.3%) and more return to work (92.7% vs 72.0%). The complication advantage was largest for tumours 2.5 cm or smaller.

For a small benign or low-grade lesion away from the main duct, enucleation appears to be a reasonable choice in experienced hands, provided the patient is counselled that a fistula is likely and usually manageable. Tumour size remained imbalanced after matching, so a prospective comparison is still needed.

• Consider enucleation over pancreatoduodenectomy for benign or low-grade pancreatic head tumours of 2.5 cm or less when technically feasible.
• Measure the distance from tumour to main pancreatic duct on preoperative imaging; it shapes fistula risk.
• Counsel patients that about 1 in 3 developed a clinically relevant fistula after enucleation.
• Explain the trade-off: fewer serious complications, shorter stay and less new diabetes than a Whipple.
• Refer to a high-volume pancreatic unit; these results come from four such centres.

Why it matters

It reframes fistula rate as only one measure: the operation with more fistulas still had fewer serious complications and better long-term function.

Don't overread it

This was a retrospective matched cohort with residual tumour-size imbalance, not a randomised comparison.

The statistics, in plain English

Propensity matching pairs similar patients, but it cannot balance what was not measured, such as the surgeon's judgement about which tumours were easy to enucleate. The size subgroup is suggestive rather than definitive.

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