Modified Blumgart Mattress Suture Versus Conventional Interrupted Suture in Pancreaticojejunostomy During Pancreaticoduodenectomy: Randomized Controlled Trial

Abstract

Objective: This study used a randomized controlled trial (RCT) to evaluate whether mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum (modified Blumgart method) during pancreaticojejunostomy (PJ) decreases the incidence of clinically relevant postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).

Background: Several studies reported that mattress suture of Blumgart anastomosis in PJ could reduce POPF rate. This, however, is the first RCT.

Methods: Between June, 2013 and May, 2017, 224 patients scheduled for PD were enrolled in this study in Wakayama Medical University Hospital. Enrolled patients were randomized to either interrupted suture or modified Blumgart mattress suture. The primary endpoint was the incidence of grade B/C POPF based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01898780).

Results: Patients were randomized to either interrupted suture (103 patients) or modified Blumgart mattress suture (107 patients) and were analyzed by intention-to-treat. Grade B/C POPF occurred in 7 patients (6.8%) in the interrupted suture group and 11 (10.3%) in the mattress suture group (P = 0.367). Mortality within 90 days was 0 in both groups. There were no significant differences in all postoperative complications between the interrupted suture group and the modified Blumgart mattress suture group.

Conclusions: Mattress suture of pancreatic parenchyma and the jejunal seromuscular layer during PJ (modified Blumgart technique) did not reduce clinically relevant POPF compared with interrupted suture.

FIGURE 1

(A) Interrupted suture method. (i) The jejunal seromuscular layer was approximated to the pancreatic parenchyma of the stump with interrupted penetrating sutures, using 4–0 MONOFLEN. (ii) Anastomosis was performed in a duct-to-mucosa fashion using a single layer of interrupted 5–0 double-armed, polydioxanone suture (PDS-II). (iii) After a 5-Fr polyethylene pancreatic stent tube was placed at the pancreaticojejunal anastomotic site during duct-to-mucosa anastomosis, suture of pancreatic parenchyma and seromuscular layer of jejunum was tied. (B) Modified Blumgart mattress suture method; transpancreatic suture starts from anterior to posterior, straight through the pancreas using 4–0 MONOFLEN. Suture was placed through the seromuscular layer of jejunal posterior wall from back to front in the direction of short axis, followed by replacement of mattress suture from front to back of posterior wall of the jejunum in the direction of the short axis, and then a full thickness pancreas bite from posterior to anterior was performed (i). Anastomosis between the pancreatic duct and mucosal layer of the jejunum was then performed (ii), and then after completion of duct-to-mucosa anastomosis and placement of internal stent, sutures were placed through the seromuscular layer of jejunal anterior wall in the direction of short axis (iii). This procedure completely covered the pancreatic stump with jejunal serosa (iv).

FIGURE 2

(A) Computed tomography (CT) finding around pancreaticojejunostomy (PJ) on postoperative day 4. We measured maximal area of interspace between the cut surface of the pancreas and jejunal wall (B) and maximal areas of intra-abdominal fluid collection around the pancreatic anastomosis at the PJ by CT findings (C).

FIGURE 3

Consort flow diagram for the trial.

FIGURE 4

Receiver-operating characteristics analyses for prediction of grade B/C postoperative pancreatic fistula (POPF) by assessment of maximal area of intra-abdominal fluid collection around the pancreatic anastomosis (A) and maximal area of interspace between pancreas and jejunum at pancreaticojejunostomy (B). The area under the curve (AUC) of intra-abdominal fluid collection was 0.873 and AUC of interspace between pancreas and jejunum was 0.756.