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

Abstract

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.

Keywords: Laparoscopic; duct-to-mucosa; pancreatic fistula; pancreaticoduodenectomy (PD); pancreaticojejunostomy (PJ).

Figure 1

Intraoperative images of SNCS. (A) An incision corresponding to the pancreatic duct was made in the jejunum; (B) posterior layer suture with continuous suture; (C) anterior layer suture with continuous sutures. SNCS, single-needle continuous suture.

Figure 2

Schematic diagram of SNCS. (A) The point of entry of the needle; (B) posterior layer suture with continuous sutures: the posterior layer of pancreatic duct-to-jejunal mucosa was stitched with three were located at 12, 9, 6 o’clock positions on the pancreatic side (point B, E, C) and 12, 3, 6 o’clock positions on the corresponding jejunum side (point B', E', C'); (C) anterior layer suture with continuous sutures: the anterior layer of pancreatic duct-to-jejunal mucosa was stitched with three stitches which were located at 12, 3, and 6 o’clock position on the pancreatic side (point B, F, C) and corresponding sites on the jejunum were 12, 9, and 6 o’clock positions (point B', F', C'). SNCS, single-needle continuous suture.

Figure 3

Intraoperative images of DLCS. (A) Posterior layer suture with continuous suture; (B) MPD and the jejunum mucous membrane was stitched with continuous suture; (C) anterior layer suture with continuous sutures. DLCS, double-layer continuous suture; MPD, main pancreatic duct.

Figure 4

Schematic diagram of DLCS. (A) Posterior layer suture with continuous suture; (B) MPD and the jejunum mucous membrane was stitched with continuous suture; (C) anterior layer suture with continuous sutures. DLCS, double-layer continuous suture; MPD, main pancreatic duct.