Comparison of pancreaticojejunostomy under the theory of mucosal priority healing with duct-to-mucosa anastomosis and invagination pancreaticojejunostomy after pancreaticoduodenectomy: A single-centre case-control study

Abstract

ObjectiveThe technological aspects of pancreaticoduodenectomy have progressed greatly, but the risk of postoperative complications, especially postoperative pancreatic fistula (POPF), postpancreatectomy haemorrhage (PPH) and mortality, is high. Therefore, we aimed to explore the safety and feasibility of pancreaticojejunostomy (PJ) under the mucosal priority healing theory through a case-control study.MethodsWe have described in detail PJ under the theory of preferential mucosal healing (PM-PJ). In a cohort of patients based on predictors of pancreatic fistula, comparisons were made according to the type of PJ: PM-PJ (n = 312); duct-to-mucosa PJ (DtoM-PJ, n = 116); and invagination PJ (IPJ, n = 109). The primary endpoint was the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). The secondary endpoints were PPH, secondary surgery, death 90 days after surgery, and other postoperative complications.ResultsThe incidence rate of CR-POPF in the PM-PJ group was not significantly different from that in the DtoM-PJ group (13.78% vs. 6.9%; p = 0.051) or the IPJ group (13.78% vs. 11.9%; p = 0.623). However, the PM-PJ group exhibited significant reductions in serious postoperative complications (7.4% versus 30.2%; p < 0.001), PPH (1.3% versus 8.4%; p < 0.001), reoperation rates (0.6% versus 9.3%; p < 0.001) and 90-day postoperative mortality rates (0.32% versus 2.6%; p = 0.023). Multivariate LASSO regression analysis revealed that BMI, hypertension, gland texture, duct size, vascular resection and pathological type were independent risk factors for CR-POPF.ConclusionsPM-PJ is safe and reliable. During surgery, there are fewer suture needles and less trauma, which may reduce the incidence of serious complications such as postoperative bleeding and mortality.

Keywords: Pancreaticojejunostomy; intestinal metaplasia; postoperative pancreatic fistula; postpancreatectomy haemorrhage; preferential mucosal healing.

Figure 1.

The anastomosis process of pancreaticojejunostomy based on the theory of mucosal priority healing (PM-PJ). (A) Intermittently suture the jejunum and pancreatic stump in a U-shape, bringing them close together without tightening, and then cut open an opening similar to the pancreatic duct in the jejunum. (B) Suture 2–3 stitches between the mucosa of the posterior wall of the jejunum and the mucosa or vicinity of the pancreatic duct. (C) Insert a support tube into the pancreatic duct and secure it slightly. (D) Complete the suturing of the mucosa of the anterior wall of the jejunum with the mucosa of the pancreatic duct or near the pancreatic duct. (E) Tighten the U-shaped suture and knot it on the surface of the jejunum to complete the anastomosis.

Figure 2.

The anastomosis process of Duct-to-mucosa pancreaticojejunostomy (DtoM-PJ). (A) The initial step involves placing interrupted sutures with 3-4/0 polypropylene thread to connect the posterior surface of the pancreatic remnant to the jejunum. (B) A duct-to-mucosa anastomosis is then performed on the posterior side. (C) On the anterior side, interrupted 5-6/0 polydioxanone sutures are used to connect the Wirsung duct to a small incision made in the jejunal loop. (D) Finally, interrupted 3-4/0 polypropylene sutures are placed between the anterior surface of the pancreatic remnant and the jejunum to complete the anastomosis.

Figure 3.

The invagination pancreaticojejunostomy (IPJ). (A) The outer layer consists of interrupted sutures using 3-4/0 polypropylene thread between the posterior aspect of the pancreatic remnant and the jejunum. (B and C) The jejunal loop is incised to a length slightly shorter than that of the pancreatic remnant, followed by a double-layered continuous suture (B) on the posterior side and (C) on the anterior side, utilizing 5-6/0 polydioxanone thread. (D) The outer layer of the anterior row is formed by interrupted sutures with 3-4/0 polypropylene thread between the anterior surface of the pancreatic remnant and the jejunum.

Figure 4.

Classification of Pancreaticoduodenectomy (PD) Into PM-PJ, IPJ and DtoM-PJ. These groups are divided into three groups based on the method of pancreatic intestinal anastomosis. The gray boxes represent PD patients who received different pancreatic intestinal anastomosis methods, the beige boxes represent the primary and secondary study objectives observed, the light green boxes represent the primary and secondary postoperative complications (POPF, PPH, 90 day mortality rate, and Reoperation), and the dark-blue boxes represent the multiple LASSO regression analysis and univariate logistic regression analysis of 537 PM-PJ patients based on whether clinically relevant pancreatic fistula occurred. CR-POPF, clinically relevant postoperative pancreatic fistula; PPH, post pancreatectomy hemorrhage; PM-PJ, pancreaticojejunostomy with priority mucosal healing; IPJ, invagination pancreaticojejunistomy; DtoM-PJ, duct-to-mucosa pancreaticojejunostomy.