A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

Abstract

Background Postoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD). Methods Ninety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed. Results All LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes. Conclusions Our technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers. Graphical abstract Our modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula

Pancreatectomy and Pancreatic Surgery

“…It has been reported that worse nutritional status can be related to a higher POPF [33]. Additionally, POPF is frequently associated with significant morbidity and mortality following PD, including intraabdominal infection, intraabdominal hemorrhage, a prolonged duration of hospitalization, indications for reoperation or less invasive (radiological or endoscopic) interventional therapy, and mortality [34].…”

“…In contrast, pancreatic metastasis and serous cystic neoplasm (SCN), a neuroendocrine neoplasm, increase the risk of POPF due to a soft pancreas and small pancreatic ducts [30]. Several surgical pancreaticojejunostomy/pancreaticogastrostomy techniques following PD, as well as pancreatic stump creation or pancreatic transection, have been introduced to reduce the risk of POPF [25,[34][35][36][37].…”