Application Of Omega-like Duct-to-mucosa Pancreatojejunostomy In Pancreatoduodenectomy

ObjectivePancreatojejunostomy is a key step in pancreatoduodenectomy,the quality of the anastomosis is closely related to postoperative complications.If pancreatic juice leaks from the pancreatojejunostomy directly to the abdominal cavity,it can cause pancreatic fistula and further cause a series of complications.The conventional duct-to-mucosa pancreatojejunostomy(Cattell-Warren pancreatojejunostomy)was used in pancreatoduodenectomy in the Department of Pancreatic-biliary Surgery,Changzheng Hospital,Shanghai before 2018.A large number of the patients would have a significant increase in the amylase level in the abdominal drainage and complications related to pancreatic fistula after Cattell-Warren pancreatojejunostomy.To decrease the pancreatic fistula rate,our team improved the conventional pancreatojejunostomy and devised the omega-like duct-to-mucosa pancreatojejunostomy.1.To illustrate the specific steps of omega-like duct-to-mucosa pancreaticojejunostomy to guide clinical practice.2.To appraise the feasibility,safety and early postoperative outcomes of omega-like duct-to-mucosa pancreatojejunostomy in pancreatoduodenectomy.Methods1.Under the guidance of the surgeon,the specific steps of omega-like duct-to-mucosa pancreatojejunostomy were illustrated utilizing operation video.2.We retrospectively analyzed 440 patients who underwent open pancreatoduodenectomy(OPD)in our department from January 2015 to December 2019.Among these patients,233 patients received CDMP from January 2015 to December 2017,and 207 patients received ODMP from January 2018 to December 2019.The primary measurements include pancreatic fistula,bile leakage,postoperative hemorrhage,delayed gastric emptying,intraperitoneal infection,ascites,and biliary tract infection.Other measurements include hepatic insufficiency,renal insufficiency,lungs infection,pleural effusion,wound dehiscence,incision infection,total patients with 1 or more complications,reoperation,in-hospital death,postoperative hospital stays,hospitalization expenses and other severe complications such as cerebral infarction,arrhythmia,aneurysm,etc.The number of patients receiving postoperative treatments such as abdominal double-cannula drainage,interventional or endoscopic therapy were also taken into consideration.3.This study retrospectively analyzed the clinical data of patients undergoing ODMP and CDMP to appraise the feasibility,safety and early postoperative outcomes of ODMP in pancreatoduodenectomy.Results1.The duration of operation(P = 0.664),intraoperative blood loss(P = 0.460)and intraoperative blood transfusion rate(P = 0.343)were not significant between the CDMP group and the ODMP group.The postoperative hospital stay(18.5 ± 10.0d vs.19.7 ± 12.3d,P = 0.248)and the hospitalization expense(120,000 ± 42,000 [Chinese Yen] vs.100,000 ±40,000 [Chinese Yen],P=0.402)were not statistically significant,but the hospitalization expense in the CDMP group was obviously higher than that in the ODMP group.2.Compared with the CDMP group,the incidence of pancreatic fistula in the ODMP group was significantly lower(42.9% vs.29.5%,P = 0.008),the incidence of clinically relevant pancreatic fistula was obviously decreased after ODMP(18.5% vs.10.6%,P =0.021).None grade C pancreatic fistula occurred in two groups,and two groups had the similar incidence of biochemical leakage(24.5% vs.18.8%,P = 0.154).3.There were 153 patients in the CDMP group and 99 patients in the ODMP group developing 1 or more complications(65.7% vs.47.8%,P=0.004).There was no difference in Clavien-Dindo Ⅲa or more compications between the CDMP group and the ODMP group(10.7% vs.11.6%,P=0.774).Compared with 55 patients in CDMP group,30 patients in ODMP group received abdominal double-cannula drainage(23.6% vs.14.5%,P= 0.016).There were 4 in-hospital deaths in the CDMP group and 4 in the ODMP group(1.7% vs.1.9%,P = 0.866).4.The univariate and multivariate analyses indicated that preoperative serum albumin level < 40g/L,CDMP,pancreatic ductal diameter ≤ 3mm,soft pancreas,benign diseases were the independent risk factors of pancreatic fistula.In subset analysis,patients undergoing ODMP with preoperative serum albumin level ≥ 40g/L(P = 0.002),soft pancreas(P = 0.002),pancreatic ductal diameter ≤ 3mm(P = 0.001),and malignant disease(P = 0.023)had lower incidence of pancreatic fistula than that in those undergoing CDMP.In the group identified a priori to be at high-risk,patients were less likely to develop pancreatic fistula after ODMP(P = 0.015).Conclusion1.ODMP is feasible,safe and easy pancreatojejunostomy in clinical practice.2.ODMP can reduce the incidence of pancreatic fistula(mainly grade B pancreatic fistula)after pancreatoduodenectomy and other early postoperative complications(mainly Clavien-Dindo I,II),and make the patient’s recovery more uneventful.3.In the group identified a priori to be at high-risk,such as soft pancreas and small pancreatic duct diameter,patients were less likely to develop pancreatic fistula after ODMP4.Compared with CDMP,ODMP can decrease the hospitalization costs of patients and has a higher cost performance.