Pancreatic Duct Holder and Mucosa Squeeze-out Technique for Duct-to-Mucosa Pancreatojejunostomy After Pancreatoduodenectomy: Propensity Score Matching Analysis.

Abstract

Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy can be technically difficult, particularly in cases with a non-dilated pancreatic duct. We devised a novel procedure employing a pancreatic duct holder and mucosa squeeze-out technique facilitating duct-to-mucosa anastomosis. We compared the perioperative outcomes of pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy between the novel and conventional procedures. Our pancreatic holder has a cone-shaped tip with a slit. The holder can expand the pancreatic duct and provides a good surgical field for anastomosis. A small incision for anastomosis is made on the jejunum, while the jejunum is grasped around the incision. Then, the jejunal mucosa becomes squeezed-out and everted. This mucosa squeeze-out technique facilitates suturing the full thickness of the jejunum. Propensity score matching yielded 113 cases each undergoing the novel and the conventional procedure, among 308 cases receiving pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy. The overall morbidity rate was significantly lower in the novel procedure group. The pancreatic fistula (ISGPF grade B/C) rate was significantly lower in the novel (5%) than in the conventional (13%) procedure group. For cases with a non-dilated pancreatic duct (≤3mm), the rate was significantly lower in the novel (10%) than in the conventional procedure group (24%). Multivariate analysis identified a non-dilated pancreatic duct, soft pancreas, and the conventional procedure as factors independently predicting the complication of pancreatic fistula formation. Our novel procedure facilitates duct-to-mucosa pancreatojejunostomy and decreases the pancreatic fistula rate. This procedure is simple, rational, and useful for achieving anastomosis, particularly in cases with a non-dilated pancreatic duct.