Chen's penetrating-suture technique for pancreaticojejunostomy following pancreaticoduodenectomy

Development and validation of a novel pancreaticojejunostomy strategy based on the anatomical location of the main pancreatic duct that can reduce the risk of postoperative pancreatic fistula after pancreatoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD). The effect of the location of the main pancreatic duct on POPF development is not completely elucidated. This study aimed to investigate the association between the location of the main pancreatic duct and POPF, and the effect of pancreaticojejunostomy based on the location of the main pancreatic duct on the risk of POPF.

Methods

This retrospective study enrolled 871 patients who underwent PD between January 2018 and December 2021. Logistic regression analysis was performed to identify the independent risk factors associated with POPF. Predictive performance was evaluated using the receiver operating characteristic curves. In addition, a novel pancreaticojejunostomy strategy that could reduce the risk of POPF was adopted.

Results

Based on the multivariate analysis, the pancreatic texture and the location of the main pancreatic duct were the independent risk factors of POPF. A threshold ratio of 0.397 was used to distinguish the central from the eccentric pancreatic ducts. Notably, patients with the central pancreatic duct had a significantly lower incidence rate of POPF than those with the eccentric pancreatic ducts (10.6% vs. 44.8%, P<0.001). The novel group exhibited a significantly lower incidence rate of POPF than the conventional group (13.7% vs. 23.0%, P=0.02), and the incidence rate of other complications was not high.

Conclusions

The location of the main pancreatic duct is associated with POPF development. However, implementing the novel pancreaticojejunostomy approach can effectively reduce the risk of POPF while ensuring safety.

A modified single-needle continuous suture of duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy

Background

The pancreatic reconstruction technique decides the incidence of postoperative pancreatic fistulas (POPF) in pancreaticoduodenectomy (PD). This study aims to evaluate the safety of modified single-needle continuous suture (SNCS) of duct-to-mucosa and compare the efficacy with double-layer continuous suture (DLCS) of duct-mucosa pancreaticojejunostomy (PJ) in open PD (OPD).

Methods

A total of 266 patients that received PD between January 2019 and May 2023 were retrospectively analyzed. Among them, 130 patients underwent DLCS, and 136 patients underwent SNCS [73 OPD and 63 laparoscopic PD (LPD)]. The primary outcome was clinically relevant POPF (CR-POPF) according to the definition of the revised 2016 International Study Group of Pancreatic Fistula (ISGPF). Propensity score matching (PSM) was conducted to reduce confounding bias.

Results

A total of 66 pairs were successfully matched using PSM in OPD. No significant difference was observed in the occurrence of CR-POPF between the two groups (9.1% vs. 21.2%, P=0.052). However, the median duration of operation and PJ was shorter in the SNCS group. The incidence of CR-POPF in LPD was 9.5%. Furthermore, regarding the alternative fistula risk score (a-FRS), the CR-POPF rate were 2.1%, 10.5%, and 15.6% in low-, intermediate-, and high-risk groups (P=0.067).

Conclusions

The SNCS is a facile, safe, and effective PJ technique and does not increase the incidence of POPF, regardless of a-FRS stratification, pancreatic texture, and main pancreatic duct (MPD) size.