A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

**Background:** Postoperative pancreatic fistula (POPF) remains a major source of morbidity and mortality after pancreaticoduodenectomy (PD). Patient-related risk factors include soft pancreatic texture and a small main pancreatic duct (MPD). The authors propose a simplified duct-to-mucosa pancreaticojejunostomy (PJ) technique, modified from the Kakita method, using only six sutures total—two duct-to-mucosa stitches and four penetrating sutures—designed to be easier to perform in minimally invasive PD (laparoscopic LPD and robotic RPD).

**Methods:** This retrospective study included 98 consecutive patients who underwent minimally invasive PD with the modified Kakita PJ at the Pancreatic Surgery Center, Zhongnan Hospital of Wuhan University, from May 2018 to March 2022. Exclusion criteria were open PD, conversion to open surgery, small retrieval incision reconstruction, or other PJ procedures. The main surgeon (Dr. Zhiyong Yang) had performed nearly 450 open PDs, 42 LPDs, and 15 RPDs prior to the study. The PJ technique used a 3-0 Prolene penetrating suture to approximate the pancreatic stump and jejunal wall, followed by two 4-0 Vicryl duct-to-mucosa sutures (posterior and anterior), and then two additional penetrating sutures at the upper and lower borders. A small silicone stent (1–3 mm) was placed in the MPD. Postoperative management included routine sandostatin, drain amylase measurement on PODs 3 and 5, and CT scans on PODs 5–7. POPF was classified per ISGPS 2017 criteria. Patients were grouped by pancreatic texture (soft vs. not-soft) and MPD diameter (≤3 mm vs. >3 mm), and also by a four-tier ISGPS risk classification.

**Key Results:** The cohort included 57 males and 41 females, median age 63 years (range 11–77), median BMI 21.43 kg/m². Soft pancreas was present in 44 patients (44.9%), and MPD ≤3 mm in 50 patients (51.0%). LPD was performed in 75 patients (76.5%) and RPD in 23 (23.5%). Median total operative time was 350 min (range 260–480), median PJ time was 17 min (range 12–25), and median blood loss was 60 mL (range 10–250), with only 1 patient (1.0%) requiring transfusion. CR-POPF (all grade B, no grade C) occurred in 4 patients (4.1%). Biochemical leaks occurred in 18 patients (18.4%). Among patients with MPD ≤3 mm, 2 of 50 (4%) had grade B POPF; among those with soft pancreas, 2 of 44 (4.5%) had grade B POPF. Neither MPD diameter nor pancreatic texture significantly impacted POPF rates (P>0.05). Using the four-tier ISGPS classification, CR-POPF rates were 3.7% (grade A), 3.7% (grade B), 4.8% (grade C), and 4.4% (grade D), with no significant differences (P=1.0). Other complications included intra-abdominal hemorrhage (3.1%), biliary fistula (5.1%), delayed gastric emptying (6.1%), intra-abdominal infection (8.2%), and pulmonary infection (3.1%). Three patients (3.1%) required reoperation. One patient (1.0%) died within 90 days (POD 23 from septic shock due to afferent loop obstruction and perforation). Median postoperative hospital stay was 17 days (range 9–101). In high-risk (benchmark) patients (n=27), CR-POPF was 11.1% vs. 1.4% in low-risk patients (n=71), but this difference was not statistically significant (P=0.11).

**Clinical Implications:** The modified Kakita PJ technique, requiring only six sutures, is associated with a low CR-POPF rate (4.1%) even in high-risk patients with soft pancreas or small MPD (≤3 mm). The technique preserves pancreatic blood supply by avoiding mobilization of the pancreatic remnant. The short median PJ time (17 min) and apparent ease of learning (stabilization achieved in fewer than 20 laparoscopic cases) suggest it may be particularly valuable for low-volume pancreatic surgery centers. Limitations include the retrospective, single-center design, small sample size, and that 72.4% of patients were low-risk. The authors acknowledge that randomized controlled trials are needed to confirm reliability.