The problem of reducing postoperative complications after pancreaticoduodenectomy (PD) remains one of the most relevant issues in modern abdominal surgery. Despite improvements in surgical techniques, mortality and morbidity after PD remain high, primarily due to the development of postoperative pancreatic fistula (POPF), which is a leading cause of fatal outcomes and often requires repeated surgical interventions. The most technically challenging stage of PD is the formation of a pancreatodigestive anastomosis (PDA). Despite many years of experience, the issue of selecting the optimal type of PDA remains a subject of scientific debate. The main reconstruction options include pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ), each of which has its own advantages and potential risks.
The aim of the study was a comparative evaluation of the effectiveness of PG and PJ in PD, with assessment of postoperative complications, characteristics of the postoperative period, functional outcomes, and the influence of the type of anastomosis on the clinical course of the disease.
The study was conducted as a prospective two-center cohort study without randomization. It included 96 patients who underwent PD between 2019 and 2023 for benign or malignant pathology of the pancreatic head and periampullary region. Surgical interventions were performed at the SI “O.O. Shalimov National Scientific Center of Surgery and Transplantology of the National Academy of Medical Sciences of Ukraine” and the SI “National Cancer Institute”.
For objective evaluation of the results of the reconstructive stage of PD, patients were divided into two groups depending on the type of pancreatodigestive anastomosis formed. Allocation was carried out according to an alternating principle (quasi-randomized design), which ensured approximately equal representation of patients in each group and minimized the risk of systematic bias. However, this approach did not exclude the influence of potential confounding factors, which was taken into account during statistical analysis.
Inclusion criteria:
• adult patients aged 18 to 80 years;
• presence of pancreatic disease without invasion into major vessels and adjacent organs;
• absence of concomitant surgical pathology that could complicate the postoperative course;
• no radiotherapy or chemotherapy before surgery.
The study groups were representative and statistically comparable in terms of the main clinical and demographic indicators. No significant differences were found between them regarding sex, age, body mass index, or the nature of the primary pathological process (p>0.05).
The study included 96 patients aged 35–74 years, with a mean age of 57.7 ± 10.5 years. Among them, 41 (42.7%) were men and 55 (57.3%) were women. The mean age in the main group was 58.1 ± 9.8 years, whereas in the comparison group it was 56.3 ± 11.0 years. The body mass index was 25.3 ± 0.7 kg/m² in the main group and 26.3 ± 3.5 kg/m² in the comparison group, indicating no statistically significant differences (p>0.05).
PD was performed for malignant neoplasms in 91 (94.7%) patients and for benign pathology in 5 (5.2%) patients.
According to the ASA anesthesiology risk classification, the condition of 17 (18.5%) patients corresponded to ASA I, while 72 (78.3%) patients were classified as ASA II, reflecting a satisfactory general somatic status in most patients before surgery.
Preoperative biliary decompression was performed in cases of hyperbilirubinemia exceeding 200 μmol/L. The main method was transpapillary biliary stenting; in cases of ineffectiveness, antegrade drainage under ultrasound guidance was applied. In the main group, preoperative drainage was performed in 30 (62.5%) patients, while in the comparison group in 27 (56.2%) patients.
PD was performed according to the classical Whipple procedure, which included cholecystectomy, transection of the common hepatic duct, resection of the distal stomach and the initial loop of the small intestine, transection of the pancreas at the level of the isthmus, and removal of regional lymph nodes within the limits of standard lymphadenectomy.
In 2019, at the SI “O.O. Shalimov National Scientific Center of Surgery and Transplantology of the National Academy of Medical Sciences of Ukraine”, an original technique for pancreaticogastrostomy formation during the reconstructive stage of PD was modified and implemented (State registration number 0624U000122). This method was applied in patients of the main group. In the comparison group, pancreaticojejunostomy was performed using the “duct-to-mucosa” principle, i.e., isolated suturing of the main pancreatic duct into the lumen of the jejunum followed by two-layer fixation of the pancreatic parenchyma to the seromuscular layer of the small intestine.
