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

Abstract

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.

Keywords: Main pancreatic duct; pancreaticoduodenectomy (PD); pancreaticojejunostomy; postoperative pancreatic fistula (POPF).

Figure 1

Study flow chart. ICC, intra-class correlation coefficient; POPF, postoperative pancreatic fistula; 1² mode, single-layer pancreaticojejunostomy with reinforcement of the anterior or posterior wall; 1 mode, single-layer pancreaticojejunostomy.

Figure 2

The intraoperative measurement diagram of an aseptic paper ruler. The central pancreatic duct (A), has a ratio of Rs/R =0.47, while the eccentric pancreatic duct (B) has a ratio of Rs/R =0.25. Rs, short distance from the center of the pancreatic duct to the edge of the pancreas; R, total thickness of the pancreas.

Figure 3

“1 mode” in pancreatoenterostomy mode. 1 mode, single-layer pancreaticojejunostomy.

Figure 4

“1² mode” in pancreatoenterostomy mode. 1² mode, single-layer pancreaticojejunostomy with reinforcement of the anterior or posterior wall. (A) If the remaining pancreatic stump could be separated, the pancreatic posterior wall tissue and the serosal layer of the jejunum can be sutured with two horizontal mattress sutures. (B) If the remaining pancreatic stump cannot be separated, the suture is passed through the posterior sides of the pancreatic tissue from behind the pancreatic duct to the posterior wall of the pancreas, and is then sutured to the serosal layer of the jejunum (two horizontal mattress sutures).

Figure 5

The ROC curves for three indicators associated with POPF. (A) The ROC curve demonstrates the correlation between the ratio of the distance from the center of the pancreatic duct to the edge of the pancreas and total pancreatic thickness, and its impact on POPF risk. (B) The ROC curve is utilized for assessing POPF risk based on the fistula risk score risk assessment. (C) The ROC curve is utilized for assessing POPF risk based on the alternative fistula risk score risk assessment. ROC, receiver operating characteristic; POPF, postoperative pancreatic fistula.