Duct-penetrating method for pancreaticojejunostomy using a suture-assistance device: outcomes of early clinical study

Abstract

Background: Suture placement around a non-dilated main pancreatic duct (MPD) in the soft pancreas has always been problematic and still requires experienced hands. We conceived a novel anastomotic technique (duct-penetrating method: DPM) using a specially prepared suture-assistance device (InnerSure Ace®). This suture placement allows appropriate suture bites around the duct without damaging the duct by lifting, pulling and pushing forces on the edge of the duct. Methods: We performed a duct-to-mucosa pancreaticojejunostomy in 44 patients using InnerSure Ace®. InnerSure Ace® is a forceps having two flexible members connected to each other at the tip, which makes a front loop. During the DPM, an atraumatic needle stabbed the cut surface of the pancreas in which the tip of the InnerSure Ace® was placed deeply into the MPD. The needle traveled along its arc and pierced both duct walls while incorporating pancreatic parenchyma with adequate depth and width around the MPD. When the needle passed through the front loop of the InnerSure Ace®, a paired thread was trapped while the instrument was withdrawn. Two suture threads were prepared by dividing the thread at the midpoint for approximation to the jejunum. Results: The average inner diameter of the duct was 1.9 ± 0.1 mm during surgery. More than 8 suture threads were placed in all patients. We encountered no grade C pancreatic fistulas and 8 patients (18.1%) with grade B fistulas. Conclusion: We achieved a safe and reliable pancreaticojejunostomy for a small-sized duct in a soft and fragile pancreas using the DPM with the InnerSure Ace®. Our anastomotic technique might become a unique clinical approach to pancreaticoenterostomy and/or duct- enterostomy. We are continuing to perform clinical investigations of the safety and utility of this novel technique using InnerSure Ace®.