Binding and interlocking pancreaticojejunostomy vs duct to mucosa pancreaticojejunostomy: A retrospective cohort study

Abstract

BACKGROUND

Pancreatic surgery has markedly evolved during the past several years with the development of minimally invasive techniques such as laparoscopy. pancreaticojejunostomy (PJ), also known as pancreatoenterostomy, is a critical step in surgical reconstruction after pancreatic resection. However, the laparoscopic performance of PJ presents additional technical challenges, especially in achieving a secure anastomosis while preserving the integrity of pancreatic tissue.

AIM

To evaluate the effectiveness and safety of binding and interlocking PJ (BIPJ) as a novel technique in laparoscopic pancreatic surgery.

METHODS

Data of patients who underwent laparoscopic pancreatic surgery from 2018 to 2023 were obtained from the hepatobiliary and pancreatic surgery database of the Second Affiliated Hospital of Zhejiang University School of Medicine and retrospectively analyzed. According to the different PJ methods used during surgery, the patients were divided into two groups: The BIPJ group and the duct-to-mucosa PJ (DMPJ) group.

RESULTS

BIPJ was performed in 33 patients, and DMPJ was performed in 34 patients. The operative time was significantly shorter in the BIPJ group (median, 340 minutes; interquartile range, 310-350) than in the DMPJ group (median, 388 minutes; interquartile range, 341-464) (P = 0.004). No significant differences were found between the DMPJ and BIPJ groups in terms of the rates of pancreatic fistula, intra-abdominal hemorrhage, intra-abdominal abscess, postoperative biliary fistula, reoperation, or postoperative hospital stay.

CONCLUSION

The suitability of laparoscopic PJ for all pancreatic textures, ability to perform full laparoscopy, shorter operation time, and comparable safety with traditional PJ make BIPJ a promising option for both surgeons and patients.

Key Words: Pancreaticojejunostomy; Binding pancreaticojejunostomy; Pancreatic surgery; Pancreatic fistula; Duct-to-mucosa pancreaticojejunostomy

Core Tip: This study introduces binding and interlocking pancreaticojejunostomy (BIPJ) as a novel technique for pancreatic surgery, comparing it with traditional duct-to-mucosa pancreaticojejunostomy. BIPJ demonstrated a significantly shorter operative time (median 340 vs 388 minutes, P = 0.004) while maintaining comparable safety profiles, including similar rates of postoperative pancreatic fistula and other complications. The technique’s adaptability to all pancreatic textures and suitability for laparoscopy make it a promising advancement. These findings suggest that BIPJ could enhance surgical efficiency without compromising patient outcomes, warranting further prospective validation.

INTRODUCTION

The utilization of laparoscopy in pancreatic surgery has gained popularity due to its potential for decreased postoperative pain, shorter hospital stays, and enhanced cosmetic outcomes[1,2]. Pancreaticojejunostomy (PJ), defined as anastomosis between the pancreatic remnant and the jejunum, plays a crucial role in pancreatic surgery, particularly within the context of the Whipple procedure. Despite advancements in surgical techniques, PJ remains one of the most challenging aspects of pancreatic surgery owing to the intricate nature and fragility of pancreatic tissue[3]. Various innovative techniques have been developed for PJ[4-6], including the duct-to-mucosa, invagination, and binding techniques, and each has distinct advantages and limitations with respect to surgical outcomes and postoperative complications[3,7,8], but there is no consensus on the most effective approach[9]. The incidence of complications after pancreaticoduodenectomy is approximately 40% to 60%, and the incidence of postoperative pancreatic fistula (POPF) is approximately 15%[10-13]. Binding PJ was first introduced by Peng et al[14] in 2002. With this technique, the pancreatic remnant is inserted into the jejunum and bound. However, control of the binding intensity is very difficult. Loose binding causes POPF, and tight binding causes pancreatic stump and jejunal ischemia, which also results in POPF[15]. In addition, when the jejunum diameter is too small or the pancreatic remnant is too large, the PJ is difficult to perform[16]. Duct-to-mucosa PJ (DMPJ), first introduced by Varco[17] in 1945, has been advocated by many surgeons[18]. However, for patients with small pancreatic ducts, performing DMPJ is difficult and time-consuming[19].

Our binding and interlocking PJ (BIPJ) is different to the binding PJ technique established by Peng et al[20], but its development was inspired by their report. BIPJ is laparoscopy-optimized to enhance surgical ergonomics during endoscopic procedures. In our technique, we bind the pancreas alone which provides a fulcrum and transfers the shear force of subsequent sutures from the pancreatic parenchyma to the binding line. This technique not only increases the tension of subsequent sutures during tensioning but also reduces the possibility of pancreatic parenchyma tearing. We conducted a retrospective cohort study to evaluate the outcome of BIPJ as a novel technique in pancreatic surgery, with a focus on its potential benefits and limitations in comparison to DMPJ.

MATERIALS AND METHODS

Study design and patients

In this retrospective cohort study, we compared two groups of patients who underwent pancreatic surgery with either BIPJ or DMPJ by the same surgical team at The Second Affiliated Hospital of Zhejiang University School of Medicine from January 2018 to December 2023. The inclusion criteria of the study were as follows: (1) Consecutive patients undergoing laparoscopic pancreatic surgery at our institution; (2) Procedures performed by the designated surgical team; and (3) Utilization of either BIPJ or DMPJ for pancreaticojejunal anastomosis. The exclusion criteria of the study were as follows: (1) Severe cardiac or renal dysfunction (New York Heart Association class III/IV or estimated glomerular filtration rate < 30 mL/minute/1.73 m²); and (2) Incomplete perioperative records (Figure 1). All surgeries were performed by an experienced pancreatic surgeon who was experienced in both laparoscopic pancreatoduodenectomy and open pancreatoduodenectomy procedures, and had performed more than 50 Laparoscopic pancreatoduodenectomies before the protocol implementation. Post-discharge monitoring included biweekly telephone follow-ups for 2 months. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013), and was approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine, No. 20231060. Informed consent was obtained from all participants.

Figure 1 Flowchart of the study. BIPJ: Binding and interlocking pancreaticojejunostomy; DMPJ: Duct to mucosa pancreaticojejunostomy.

Operative procedure

The surgical procedure was performed as follows: (1) The patient was placed in the supine position and administered general anesthesia via an endotracheal tube. The surgical area was disinfected using a towel; (2) A small arc-shaped incision was made at the umbilicus for insertion of a pneumoperitoneum needle into the abdominal cavity. Carbon dioxide gas was then injected to create a pneumoperitoneum at 15 mmHg. Abdominal puncture was performed under laparoscopic guidance for placement of a trocar following removal of the pneumoperitoneum needle. Various operating instruments were accommodated by inserting four additional trocars; (3) The abdominal cavity was explored, and pancreaticoduodenectomy was performed based on the examination findings; (4) The surgical procedure involved making incisions in the right gastrocolic ligament and separating it from the lower margin of the pancreas up to the superior mesenteric vein. The lesser omentum was opened by severing the right gastric artery and gastroduodenal artery. The celiac trunk and hepatic para-aortic lymph nodes were dissected. The anterior wall of the portal vein was separated from the back to the top along the superior mesenteric vein, and no tumor invasion was observed. Finally, the stomach was severed with a linear cutter at the junction between the antrum and body; (5) The hepatoduodenal ligament was dissected, and the common bile duct was freed along with the portal vein and hepatic artery. The hepatoduodenal lymph nodes were cleaned, and the gallbladder was freed with ligation of the gallbladder artery. The hepatic duct was severed 1 cm above its confluence with the common bile duct; (6) The right end of the transverse colon and the hepatic flexion were freed through a Kocher incision, and the duodenal bulb, descending duodenum, and transverse duodenum were also released. The jejunum was cut approximately 10 cm below the ligament of Treitz, and the proximal portion was isolated behind the superior mesenteric artery; (7) The pancreas was progressively cut off on the left side of the superior mesenteric vein until complete removal; (8) The distal portion of the stomach, pancreatic head, duodenum, and upper segment of the jejunum were retracted to the right side for exposure of the superior mesenteric arteriovenous tissue and blood vessels. The uncinate process of the pancreas and interarteriovenous tissue of the superior mesentery were dissected from bottom to top, followed by division using a Hem-o-lok clamp. The specimen was completely mobilized and subsequently removed; (9) BIPJ was employed following pancreaticoduodenectomy. Pancreas texture was judged by 3-4 experienced surgeons on the team; (10) End-to-side anastomosis between the choledo-jejunum was performed with all openings created on the contralateral margin of the jejunal mesentery, matching the length of the bile duct opening. This was followed by continuous full-thickness suturing; (11) Lateral anastomosis was accomplished using the distal jejunum and posterior wall of the stomach anterior to the colon; and (12) Closure involved suturing the mesangial space, thorough abdominal cavity irrigation, precise hemostatic control, placement of drainage tube(s), and layered closure.

The BIPJ procedure was performed as follows (Figure 2): (1) A figure-of-eight suturing technique was used to secure the pancreatic stent tube in the main pancreatic duct. The tube was approximately 15 cm in length and had two to three lateral side holes at its insertion end; (2) A slightly thicker suture, such as No. 7, was used to bind the pancreas approximately 1 to 2 cm away from the remaining end, adjusting the tension appropriately to avoid damaging the integrity of the pancreatic tissue. This maneuver transformed the flat remnant end of the pancreas into a circular configuration; (3) A 3-0 monofilament non-absorbable polypropylene suture was used to secure the pancreatic tissue to the jejunal sidewall. Beginning from the ventral side of the pancreas, the needle was inserted through the dorsal side and passed parallel to the long axis of the jejunum from the opposite side of the mesentery. The needle traversed through the muscular layer and exited after traveling a distance slightly greater than the diameter of the circular remnant end of the pancreas. The needle was inserted from the dorsal side of the pancreas and traversed to the ventral side, and a knot was then tied to create a one-armed U-shaped suture between the pancreas and the jejunal sidewall; (4) A small hole was created in the jejunum at the corresponding location for a drainage tube using an electric hook. The drainage tube was inserted into this small hole and secured with a figure-of-eight suturing technique; and (5) A double-layer continuous suturing technique was used to close the anterior wall of the jejunum and anterior wall of the pancreas. For the first inner layer, the needle was inserted near the pancreatic head along the ligature line. For the second outer layer, the needle was inserted near the pancreatic tail approximately 8 mm away from the previous suture along the ligature line.

Figure 2 Schematic illustration of the binding locking pancreaticojejunostomy technique. A: A pancreatic duct stent was placed and fixed with a figure-of-eight suture; B: The pancreas was bound; C: A one-armed U-shaped suture was created between the pancreas and jejunal sidewall; D: A drainage tube was inserted into the small hole and secured with a figure-of-eight suturing technique; E: Continuous suture in the anterior wall of the jejunum and the anterior wall of the pancreas; F: Another one-armed U-shaped suture was created between the pancreas and jejunal sidewall; G: Finally the binding and interlocking state was created.

Postoperative management

After pancreaticoduodenectomy, all patients were treated according to a standardized nursing protocol. The drainage tube was managed as follows: Two 10-mm flat, 3/4 fluted silicone drainage tubes were placed near the pancreatic anastomosis. If the drainage fluid was clear and no pancreatic fistula or bacterial contamination was present, the drainage tube was removed within 7 to 14 days. The amylase level in the drainage fluid was also checked. All patients received prophylactic octreotide to prevent POPF.

Data collection

Demographic and clinical data, including age, sex, underlying diagnosis, operative details, and postoperative outcomes, were collected from electronic medical records. To ensure accuracy and completeness, all data were collected by trained research personnel and reviewed by the study investigators.

Outcomes

The primary outcomes of interest were POPF, delayed gastric emptying, postoperative hemorrhage, and overall postoperative complications. The secondary outcomes were operative time, length of hospital stay, and mortality within 30 days.

Definitions of complications

According to the definitions established by the International Study Group on Pancreatic Fistula, postoperative complications were diagnosed as follows[21]: (1) Pancreatic fistula: Drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content of > 3 times the serum amylase activity; (2) Delayed gastric emptying: Continuous decompression for > 10 days; (3) Postoperative hemorrhage: Packed red blood cell transfusion of > 3 U 24 hours after surgery; (4) Biliary fistula: Output of biliary-rich fluid for > 5 days or confirmation by cholangiography or fistula angiography; and (5) Abdominal collection: Intraperitoneal fluid of > 5 cm confirmed by computed tomography or ultrasound with or without clinical symptoms.

Statistical analysis

Descriptive statistics were used to summarize the demographic and clinical characteristics of the study population. Continuous variables are presented as mean ± SD or median with interquartile range (IQR), and categorical variables are presented as frequency and percentage. Normally distributed continuous variables were compared using t-tests, non-normal data with Mann-Whitney U tests. Categorical variables were analyzed with χ² or Fisher’s exact tests (expected frequency < 5). All statistical analyses were performed using R version 4.2.2 with MSTATA software.

RESULTS

Comparison of general data and pancreatic fistula risk

We retrospectively analyzed 33 patients who underwent BIPJ and 34 patients who underwent DMPJ. No significant differences were found between the two groups in patients’ baseline characteristics, including body mass index, hypertension, diabetes, preoperative biliary drainage, neoadjuvant therapy, and various laboratory parameters (Table 1). There were no significant differences in pancreatic texture, main pancreatic duct diameter, or pancreatic fistula risk classification between the groups (Table 2). Pancreatic fistula risk was classified according to the 2023 updated criteria from the International Study Group of Pancreatic Surgery[22].

Table 1 Patient demographics and baseline characteristics, n (%).

Preoperative variables	Technique		P value
	DMPJ, n = 34	BIPJ, n = 33
Age, years	62 (57, 70)	66 (59, 73)	0.144
Gender, male	21 (62)	14 (42)	0.158
BMI, kg/m2	23.02 ± 2.89	21.80 ± 3.48	0.124
Hypertension, yes	12 (35)	14 (42)	0.549
Diabetes, yes	7 (21)	5 (15)	0.562
Preoperative biliary drainage, yes	0 (0)	2 (6)	0.239
Neoadjuvant therapy, yes	6 (18)	1 (3)	0.105
White blood cells, × 109/L	6.70 (5.03, 8.03)	6.40 (5.30, 7.60)	0.726
Hemoglobin, g/L	122 ± 24	122 ± 19	0.967
Aspartate aminotransferase, U/L	39 (20, 73)	32 (21, 85)	0.757
Alanine aminotransferase, U/L	33 (22, 60)	36 (24, 101)	0.309
Total bilirubin, μmol/L	15 (10, 64)	19 (13, 159)	0.229
Direct bilirubin, μmol/L	3 (2, 18)	2 (0, 88)	0.591
Blood creatinine, μmol/L	69 (57, 80)	61 (55, 72)	0.185
Blood urea nitrogen, mmol/L	4.39 (3.60, 5.95)	4.36 (3.35, 5.44)	0.580
Serum albumin, g/L	39.0 ± 4.4	36.9 ± 4.4	0.089
C-reactive protein	6.1 (2.5, 33.7)	7.7 (2.9, 25.8)	0.763

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy; BMI: Body mass index.

Table 2 Risk factors for pancreatic fistula, n (%).

Variables	Technique		P value
	DMPJ, n = 34	BIPJ, n = 33
Pancreatic texture of remnant pancreas			0.162
Soft	26 (76)	20 (61)
Hard	8 (24)	13 (39)
Main pancreatic duct size			0.393
≤ 3 mm	15 (44)	18 (55)
> 3 mm	19 (56)	15 (45)
Pancreatic fistula risk classification			0.447
A	6 (18.2)	5 (14.7)
B	7 (21.2)	3 (8.82)
C	9 (27.3)	14 (41.2)
D	11 (33.3)	12 (35.3)

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy.

Operative outcomes and postoperative complications

The operative time was significantly shorter in the BIPJ group (median, 340 minutes; IQR: 310-350) than in the DMPJ group (median, 388 minutes; IQR: 341-464) (P = 0.004). There were no significant differences in hemorrhage or blood transfusion between the groups (Table 3). Analysis revealed no significant differences in the rates of pancreatic fistula, intra-abdominal hemorrhage, intra-abdominal abscess, postoperative biliary fistula, reoperation, or postoperative hospital stay between the DMPJ and BIPJ groups (Table 4).

Table 3 Operative outcomes, n (%).

Variables	Technique		P value
	DMPJ, n = 34	BIPJ, n = 33
Operative time, minutes	388 (341, 464)	340 (310, 350)	0.004
Intraoperative bleeding, mL	200 (200, 275)	200 (100, 200)	0.431
Red blood cell transfusion	100 (0, 400)	0 (0, 100)	0.062
Final pathological diagnosis			0.452
Pancreatic cancer	21 (62)	18 (55)
Neuroendocrine tumor	7 (21)	1 (3)
Ampullary neoplasm	1 (3)	5 (15)
Duodenal cancer	2 (6)	5 (15)
Intraductal papillary mucinous neoplasm	3 (9)	2 (6)
Pancreatic serous cystadenoma	0 (0)	1 (3)
Bile duct cancer	0 (0)	1 (3)

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy.

Table 4 Postoperative complications, n (%).

Variables	Technique		P value
	DMPJ, n = 34	BIPJ, n = 33
Pancreatic fistula			0.183
None	10 (29)	17 (52)
Biochemical leakage	7 (21)	6 (18)
Grade B	15 (44)	7 (21)
Grade C	2 (6)	3 (9)
Intra-abdominal hemorrhage, yes	2 (6)	3 (9)	0.673
Intraabdominal abscess, yes	1 (3)	1 (3)	1.000
Postoperative biliary fistula, yes	0 (0)	1 (3)	0.493
Postoperative chylous fistula, yes	6 (18)	1 (3)	0.105
Reoperation, yes	2 (6)	0 (0)	0.493
Postoperative hospital stay, days	18 (15, 27)	18 (14, 22)	0.400
Hospitalization costs, × 104 yuan	1223 (1009, 1519)	1028 (921, 1353)	0.071
Mortality within 30 days	0 (0)	0 (0)	1.000

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy.

Subgroup analysis

The subgroup analysis revealed that regardless of the diameter of the main pancreatic duct, the operative time for BIPJ was shorter than that for DMPJ, and the difference was statistically significant when the pancreatic duct was < 3 mm (P = 0.031). There were no significant differences in complication rates for other postoperative outcomes, including pancreatic fistula, intra-abdominal hemorrhage, and reoperation (Table 5). Regardless of whether the pancreas was soft or hard, there was no significant difference between the two techniques in terms of complication rates (Table 6).

Table 5 Subgroup analysis of main pancreatic duct size, n (%).

Variables	Main pancreatic duct size (≤ 3 mm), n = 33			Main pancreatic duct size (> 3 mm), n = 34
	DMPJ, n = 15	BIPJ, n = 18	P value	DMPJ, n = 19	BIPJ, n = 15	P value
Operative time, minutes	380 (330, 450)	340 (311, 345)	0.031	410 (345, 488)	340 (308, 403)	0.066
Intraoperative bleeding, mL	200 (150, 200)	200 (100, 200)	0.592	200 (200, 300)	200 (100, 350)	0.886
Red blood cell transfusion	200 (0, 450)	0 (0, 0)	0.003	0 (0, 390)	100 (0, 450)	0.752
Pancreatic fistula			0.817			0.090
None	4 (27)	8 (44)		6 (32)	9 (60)
Biochemical leakage	3 (20)	3 (17)		4 (21)	3 (20)
Grade B	7 (47)	6 (33)		8 (42)	1 (7)
Grade C	1 (7)	1 (6)		1 (5)	2 (13)
Intra-abdominal hemorrhage, yes	2 (13)	1 (6)	0.579	0 (0)	2 (13)	0.187
Intraabdominal abscess, yes	1 (7)	0 (0)	0.455	0 (0)	1 (7)	0.441
Postoperative biliary fistula, yes	0 (0)	1 (6)	1.000	0 (0)	0 (0)	1.000
Postoperative chylous fistula, yes	3 (20)	0 (0)	0.083	3 (16)	1 (7)	0.613
Reoperation, yes	1 (7)	0 (0)	0.455	1 (5)	0 (0)	1.000
Postoperative hospital stay, days	18 (15, 29)	18 (13, 24)	0.246	17 (16, 23)	18 (16, 21)	0.945

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy.

Table 6 Subgroup analysis of pancreatic texture, n (%).

Variables	Pancreatic texture of remnant pancreas (soft), n = 46			Pancreatic texture of remnant pancreas (hard), n = 21
	DMPJ, n = 26	BIPJ, n = 20	P value	DMPJ, n = 8	BIPJ, n = 13	P value
Operative time, minutes	403 (351, 469)	335 (300, 345)	0.001	365 (301, 421)	340 (325, 395)	0.856
Intraoperative bleeding, mL	200 (200, 300)	100 (100, 200)	0.023	200 (50, 200)	200 (200, 300)	0.049
Red blood cell transfusion	100 (0, 400)	0 (0, 100)	0.095	100 (0, 325)	0 (0, 0)	0.365
Pancreatic fistula			0.817			0.090
None	6 (23)	12 (60)		4 (50)	5 (38)
Biochemical leakage	5 (19)	2 (10)		2 (25)	4 (31)
Grade B	13 (50)	4 (20)		2 (25)	3 (23)
Grade C	2 (8)	2 (10)		0 (0)	1 (8)
Intra-abdominal hemorrhage, yes	2 (8)	2 (10)	1.000	0 (0)	1 (8)	1.000
Intraabdominal abscess, yes	1 (4)	1 (5)	1.000	0 (0)	0 (0)	1.000
Postoperative biliary fistula, yes	0 (0)	1 (5)	0.435	0 (0)	0 (0)	1.000
Postoperative chylous fistula, yes	4 (15)	1 (5)	0.369	2 (25)	0 (0)	0.133
Reoperation, yes	2 (8)	0 (0)	0.498	0 (0)	0 (0)	1.000
Postoperative hospital stay, days	19 (16, 32)	18 (16, 25)	0.498	17.0 (14.8, 18.0)	17.0 (13.0, 21.0)	0.942

DMPJ: Duct to mucosa pancreaticojejunostomy; BIPJ: Binding and interlocking pancreaticojejunostomy.

DISCUSSION

The present study on BIPJ as a novel technique in pancreatic surgery has shown promising outcomes, making it a versatile option for a wide range of patients undergoing laparoscopic pancreatic surgery. This is particularly important as pancreatic textures can vary greatly among patients, and having a technique that can be applied universally is advantageous. Our clinical practice has concluded that this technique is effective in open, laparoscopic, and robotic-assisted laparoscopic pancreatic surgery.

The current consensus is that in order to ensure the safety and reliability of PJ, the following requirements should be met: The pancreatic section is fully fitted to the jejunal serous membrane, pancreatic fluid drainage is smooth, tearing of the pancreatic parenchyma by the sutures is minimal, the pancreatic stump blood flow is unobstructed, and the risk of an accessory pancreatic duct fistula is minimized[23-25]. One study suggested that for patients with a soft pancreas texture and pancreatic duct diameter of < 3 mm, the DMPJ may increase the risk of a pancreatic fistula[19].

In our BIPJ technique, we bind the pancreas so that the pancreatic stump changes from oval to approximately circular. This shape is conducive to uniform adhesion of the subsequent pancreatic stump to the wall of the empty intestine. The pancreatic duct stent is fixed by binding and suturing to reduce the dead space between the stent and the pancreatic duct. This also serves to clamp the paracolic duct. The binding line provides a fulcrum and transfers the shear force of the subsequent sutures from the pancreatic parenchyma to the binding line, forming an interlocking state between the binding line and the U-shaped suture. This not only increases the tension of the subsequent sutures when tensioning but also reduces the possibility of tearing the pancreatic parenchyma. Therefore, this method is particularly suitable for a pancreas with a soft texture. Our technique also reduces the need for multiple sutures to the pancreatic duct. Thus, even pancreatic ducts of smaller diameter do not increase the difficulty of the procedure. In addition, the technique involves only one suture at each step, and each suture is immediately knotted. This avoids the risk of two suture knotting errors and is convenient when performing a laparoscopic operation.

In addition to its wide range of application scenarios, our research also shows that the BIPJ technique is associated with a shorter operation time than that of traditional PJ. The shorter operative time indicates the efficiency of this novel technique in pancreatic surgery. Furthermore, the safety profile of the BIPJ technique was found to be similar to that of traditional PJ. This is a crucial consideration for any new surgical technique because patient safety is paramount. The comparable safety outcomes suggest that this novel technique does not compromise patient well-being and may offer advantages in terms of operative time and the potential for improved postoperative outcomes. While not statistically significant, the BIPJ group showed a trend toward fewer postoperative chylous fistula events and lower hospitalization costs vs DMPJ (Table 3), a difference that might become significant with larger cohorts.

PJ is a key part of pancreatic surgery, and its quality directly affects the occurrence of postoperative complications. Several PJ techniques are currently available, but none can completely avoid pancreatic leakage. Additionally, no study has confirmed the superiority of any method[9]. The advantage of this technique is that it is applicable to all pancreatic textures, can perform full laparoscopy, has a shorter operation time, and is comparable in safety to traditional PJ. However, this study also has some limitations. Firstly, this is a retrospective single center study. Secondly, the limited number of cases in this study can lead to bias. Therefore, further prospective multicenter studies and long-term follow-up are needed in the future to validate these findings and establish the long-term efficacy and safety of this new technique.

CONCLUSION

The suitability of this technique for all pancreatic textures, ability to perform full laparoscopy, shorter operation time, and comparable safety compared with traditional PJ make it a promising option for surgeons and patients alike.