title: Changing indications for a total pancreatectomy: perspectives over a quarter of a century.
abstract: BACKGROUND
  The indications for a total pancreatectomy (TP), its peri-operative management, provision of pancreatic surgical services and medical treatment of the inherent exo- and endocrine deficient states have all changed considerably over recent decades. The effects of these upon the incidence, indications for and outcomes of TP are unclear. Patients undergoing TP at a single institution over a quarter of a century were reviewed to try to address these issues.
  
  
  METHODS
  Data on patients who underwent elective (el-) and emergency TP (em-TP) between 1987 and 2013 were reviewed. Patient demographics, indications, intra-operative details, peri-operative management and long-term outcomes were analysed. Absolute numbers of TP were reported relative to partial pancreatectomy rates.
  
  
  RESULTS
  In total, 136 patients underwent TP [98 (72.1%) el-TP; 38 (27.9%) em-TP]. There was a significant change in indication for el-TP with it increasingly performed for (an intraductal papillary mucinous neoplasm (IPMN) and renal cell metastases whereas there was a decrease in the number of el-TP performed for chronic pancreatitis (P = 0.025). The relative rates of el-TP, however, did not change significantly across the study period (P = 0.225). The median length of stay after el-TP decreased from 19 days pre-1997 to 12 days post-1997 (P = 0.009). The relative use of em-TP declined by 0.28 percentage points per year [P = 0.018; 95% confidence interval (CI): 0.04-0.41].
  
  
  CONCLUSIONS
  The indications for el-TP have changed; it is being performed more frequently although the proportion relative to other pancreatic resections has not changed. A decrease in the rate of em-TP is likely to reflect improved peri-operative management of a pancreatic fistula and its complications after a pancreaticoduodenectomy.
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Max
authors.initials: M
authors.lastname: Almond
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Roberts
authors.forename: James
authors.initials: J
authors.lastname: Hodson
authors.forename: Robert
authors.initials: R
authors.lastname: Sutcliffe
authors.forename: Ravi
authors.initials: R
authors.lastname: Marudanayagam
authors.forename: John
authors.initials: J
authors.lastname: Isaac
authors.forename: Paolo
authors.initials: P
authors.lastname: Muiesan
authors.forename: Darius
authors.initials: D
authors.lastname: Mirza
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods* / Q000639:trends*; D010182:Pancreatic Diseases / Q000601:surgery*; D012189:Retrospective Studies; D055815:Young Adult