Comparison of the modified Blumgart mattress vs. interrupted suture pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy

Abstract

Aim: The modified Blumgart mattress (BM) and conventional interrupted suture (IS) methods are currently the most widely adopted pancreaticojejunostomy (PJ) techniques utilized during minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the postoperative outcomes between the two PJ techniques using robotic and laparoscopic approaches.

Methods: This was a retrospective study involving patients who underwent robotic or laparoscopic pancreaticoduodenectomy (PD) performed by two surgeons from two institutions. Surgical outcomes of the patients were compared according to the PJ techniques of robotic BM (Rob-BM), robotic IS (Rob-IS), and laparoscopic IS (Lap-IS), which were further analyzed among patients who had a soft pancreas and small pancreatic duct, while those with pancreatic ductal adenocarcinoma were excluded from the study.

Results: A total of 230 patients underwent MIPD with 63 Rob-BM, 48 Rob-IS, and 119 Lap-IS for PJ. Within the study population, clinically relevant-postoperative pancreatic fistula (CR-POPF) rates were comparable between Rob-BM and Rob-IS (6.3% vs. 10.4%, P = 0.283) and between Rob-IS and Lap-IS (10.4% vs. 7.6%, P = 0.661). Comparing patients with soft pancreas and small pancreatic duct, CR-POPF rates were not statistically different among the groups [16.0% (Rob-BM) vs. 10.5% (Rob-IS), P = 0.055, and 10.5% (Rob-IS) vs. 10.1% (Lap-IS), P = 0.543]. In the multivariable analysis for risk factors of POPF, soft pancreatic textures and periampullary pathology other than pancreatic cancer were found to be risk factors.

Conclusion: POPF rates after MIPD were not different according to the PJ methods of BM and IS when performed by skilled surgeons.

Keywords

Pancreaticoduodenectomy / pancreatic reconstruction / pancreatic fistula / robot / laparoscopy

References

[1] McMillan MT.Predictive factors for pancreatic fistula following pancreatectomy.Langenbecks Arch Surg2014;399:811-24

[2] Vining CC,Schuitevoerder D.Risk factors for complications in patients undergoing pancreaticoduodenectomy: a NSQIP analysis with propensity score matching.J Surg Oncol2020;122:183-94

[3] Panni RZ,Hawkins WG,Asbun HJ.National pancreatic fistula rates after minimally invasive pancreaticoduodenectomy: a NSQIP analysis.J Am Coll Surg2019;229:192-199.e1

[4] Buren G 2nd, Vollmer CM Jr. The landmark series: mitigation of the postoperative pancreatic fistula.Ann Surg Oncol2021;28:1052-9

[5] Cheng Y,Lai M.Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy.Cochrane Database Syst Rev2017;9:CD012257 PMCID:PMC6483797

[6] Bai X,Gao S.Duct-to-mucosa vs invagination for pancreaticojejunostomy after pancreaticoduodenectomy: a prospective, randomized controlled trial from a single surgeon.J Am Coll Surg2016;222:10-8

[7] Ricci C,Taffurelli G,Beltrami D.Is pancreaticogastrostomy safer than pancreaticojejunostomy after pancreaticoduodenectomy?.Pancreatology2017;17:805-13

[8] Kilambi R.Duct-to-mucosa versus dunking techniques of pancreaticojejunostomy after pancreaticoduodenectomy: do we need more trials? A systematic review and meta-analysis with trial sequential analysis.J Surg Oncol2018;117:928-39

[9] Kleespies A,Seeliger H,Jauch KW.Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection.Br J Surg2009;96:741-50

[10] Fujii T,Yamada S.Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study.J Gastrointest Surg2014;18:1108-15

[11] Kojima T,Watanabe N,Mimura T.Modified Blumgart anastomosis with the “complete packing method” reduces the incidence of pancreatic fistula and complications after resection of the head of the pancreas.Am J Surg2018;216:941-8

[12] Eshmuminov D,Tschuor C.Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture.HPB (Oxford)2018;20:992-1003

[13] Schulz KF,Moher D.CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.Obstet Gynecol2010;115:1063-70

[14] Schulz KF,Moher D.CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.BMJ2010;340:c332 PMCID:PMC2844940

[15] Chong EH.Hybrid laparoscopic and robotic hepatopancreaticoduodenectomy for cholangiocarcinoma.J Gastrointest Surg2019;23:1947-8

[16] Bassi C,Dervenis C.International Study Group on Pancreatic Surgery (ISGPS)The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after.Surgery2017;161:584-91

[17] Clavien PA,de Oliveira ML.The clavien-dindo classification of surgical complications: five-year experience.Ann Surg2009;250:187-96

[18] Wente MN,Bassi C.Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.Surgery2007;142:20-5

[19] Wente MN,Dervenis C.Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).Surgery2007;142:761-8

[20] Mazuski JE,May AK.The surgical infection society revised guidelines on the management of intra-abdominal infection.Surg Infect2017;18:1-76

[21] Koch M,Padbury R.Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery.Surgery2011;149:680-8

[22] Belyaev O,Meier JJ.Assessment of pancreatic hardness-surgeon versus durometer.J Surg Res2010;158:53-60

[23] Hashimoto Y,Takahashi N.Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy.J Gastrointest Surg2011;15:2193-204

[24] Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.Int J Surg2014;12:1495-9

[25] Casadei R,Ingaldi C,De Raffele E.Comparison of blumgart anastomosis with duct-to-mucosa anastomosis and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a single-center propensity score matching analysis.J Gastrointest Surg2021;25:411-20

[26] Clemente G,Panettieri E.Pancreatico-jejunostomy on isolated loop after pancreatico-duodenectomy: is it worthwhile?.J Gastrointest Surg2022;26:1205-12 PMCID:PMC9184425

[27] Greene BS,Peoples JB.Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?.Am J Surg1991;161:45-9; discussion 49

[28] Choi SH,Kang CM,Lee WJ.A dog model of pancreaticojejunostomy without duct-to-mucosa anastomosis.JOP2012;13:30-5

[29] WARREN KW.Basic techniques in pancreatic surgery.Surg Clin North Am1956;36:707-24

[30] Grobmyer SR,Blumgart LH.Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.J Am Coll Surg2010;210:54-9

[31] Bassi C,Molinari E.Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial.Surgery2003;134:766-71

[32] Hirono S,Okada KI.Modified blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy: randomized controlled trial.Ann Surg2019;269:243-51 PMCID:PMC6325750

[33] Chen YJ,Lau WY.Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature.Int J Surg2014;12:706-11

[34] Cao F,Li A,Li F.Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy.Asian J Surg2020;43:1056-61

[35] Kawakatsu S,Mise Y.Comparison of pancreatojejunostomy techniques in patients with a soft pancreas: Kakita anastomosis and Blumgart anastomosis.BMC Surg2018;18:88 PMCID:PMC6201584

[36] Hogg ME,Novak S.Grading of surgeon technical performance predicts postoperative pancreatic fistula for pancreaticoduodenectomy independent of patient-related variables.Ann Surg2016;264:482-91

[37] Aoki S,Konno H.Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan.J Hepatobiliary Pancreat Sci2017;24:243-51 PMCID:PMC5516144

[38] Kobayashi S,Hoshino H.Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks.J Hepatobiliary Pancreat Sci2018;25:231-9

[39] Chang EH,Smith MC.Obesity and surgical complications of pancreaticoduodenectomy: an observation study utilizing ACS NSQIP.Am J Surg2020;220:135-9

[40] Kang CM,Lee WJ.Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages?.Surg Endosc2011;25:2004-9

[41] Yeo CJ.Management of complications following pancreaticoduodenectomy.Surg Clin North Am1995;75:913-24

[42] Yamaguchi K,Chijiiwa K,Imamura M.Early and late complications of pylorus-preserving pancreatoduodenectomy in Japan 1998.J Hepatobiliary Pancreat Surg1999;6:303-11

[43] Martignoni ME,Sell F.Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection.Am J Surg2000;180:18-23

[44] Lin PW.Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy.Br J Surg1999;86:603-7

[45] Jimenez RE,Rattner DW,Warshaw AL.Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis.Ann Surg2000;231:293-300 PMCID:PMC1420999

[46] Seiler CA,Bachmann T.Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results.Br J Surg2005;92:547-56

[47] Qu H,Zhou SQ.Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis.Eur J Surg Oncol2013;39:213-23

[48] Adam MA,Youngwirth L,Roman SA.Defining a hospital volume threshold for minimally invasive pancreaticoduodenectomy in the united states.JAMA Surg2017;152:336-42 PMCID:PMC5470427