The improvement of pancreatic duct stent tube in internal drainage during pancreaticojejunostomy—surgical technique

Introduction

Since Codivilla’s pioneering pancreaticoduodenectomy (PD) for pancreatic head carcinoma in 1898, the technique of pancreaticojejunostomy (PJ) has undergone significant exploration and refinement, with its evolution spanning over a century of surgical innovation (1). Currently, numerous innovations in PJ techniques have been developed. Existing literature documents over 50 distinct procedural variations being implemented in contemporary surgical practice (2). The primary clinical anastomosis techniques in PJ comprise the following approaches: end-to-end pancreatojejunal anastomosis, duct-to-mucosa PJ, binding PJ, and Blumgart anastomosis, among others (3,4).

The critical determinant for successful PJ lies in achieving optimal pancreatic juice drainage. Pancreatic duct stent drainage methods can be categorized into internal and external approaches. Current clinical research evidence indicates that internal stent placement has a high level of safety in reducing postoperative complications associated with PJ (5). Internal drainage is a relatively ideal surgical method for preventing pancreatic fistula after PD, as it is simple to operate and has the dual advantages of avoiding pancreatic fluid loss and preventing complications related to external drainage (6). The introduction of pancreatic duct stenting has emerged as a novel strategy to further mitigate postoperative pancreatic fistula (POPF) incidence in PJ. This technique achieves dual protection by maintaining physiological separation of pancreatic secretions from the anastomotic site to prevent corrosive damage, while simultaneously providing mechanical stabilization of the main pancreatic duct lumen to ensure unobstructed pancreatic drainage.

Recent clinical observations have found that complications after pancreatic duct stent placement are worrying, mainly including stent perforation of the intestinal wall, stent displacement, pancreatic duct obstruction and abnormal pancreatic duct morphology, etc. (6).

Recently, our team has also encountered two cases of severe postoperative complications associated with this type of pancreatic duct stent. The first involved a 60-year-old male who presented with active intra-abdominal bleeding on postoperative day 10 following open PD. The second case occurred in a 53-year-old female who developed similar complications 7 days after laparoscopic pancreaticoduodenectomy (LPD). Exploratory laparotomy in both patients revealed that the stent tube had perforated the intestinal wall, creating a conduit for pancreatic juice leakage into the peritoneal cavity. Subsequent analysis indicated that the proteolytic enzymes in pancreatic secretions caused vascular wall erosion, ultimately leading to vessel rupture and life-threatening hemorrhage (Figure 1).

Figure 1 The stent tube had perforated the intestinal wall.

In response to these clinical challenges, our research team has developed a novel stent design incorporating key modifications to address these complications. The redesigned device features optimized structural parameters and material composition aimed at enhancing biocompatibility while reducing mechanical stress on pancreatic ductal architecture. This innovation was motivated by the critical need to mitigate procedure-related adverse events and improve long-term clinical outcomes in pancreatic interventions. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-342/rc).

Preoperative preparations and requirements

Patients

This study enrolled 33 patients who had undergone PJ using the newly improved pancreatic duct stent tube from January 2021 to January 2023.

Inclusion and exclusion criteria

Inclusion criteria

Patients were diagnosed with distal bile duct tumors, duodenal tumors, or pancreatic head tumors via imaging examinations, including ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI). These patients met the surgical indications for PD and required treatment with PJ.

Exclusion criteria

Pancreatic body/tail lesions; benign pancreatic diseases; and severe cardiopulmonary dysfunction.

All patients underwent preoperative examinations, with confirmed surgical indications and absence of contraindications. The team conducted a preoperative discussion regarding the necessity of performing PJ. Informed consent was obtained from both patients and their families. All surgeries were performed by the same surgical team.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second Affiliated Hospital of Nanchang University (IIT-O-2024-214). Informed consent was waived by the Ethics Committee for this retrospective study due to the exclusive use of de-identified patient data, which posed no potential harm or impact on patient care.

Step-by-step description

Improved method of drainage stent tube

The first technique involves direct placement of a silicone catheter featuring a distal bulbous tip (e.g., ventricular drainage catheter) as a pancreatic ductal stent (Figures 2,3). The first approach employs a stent tube with a nominal diameter of 2.0/2.7/3.3 mm, particularly suitable for pancreatic ducts exhibiting larger luminal dimensions.

Figure 2 Conceptual diagram of the first improved design of the pancreatic stent.

Figure 3 The first improved design of the pancreatic stent.

Alternatively, the second methodology involves customized fabrication of drainage tubes based on individual pancreatic duct measurements, incorporating a bulbous modification at the proximal extremity to enhance retention (Figure 4). This anatomical adaptation mimics the structural characteristics of ventricular drainage systems while maintaining compatibility with pancreatic ductal architecture. The diameter of such stent tubes is generally less than 1.5 mm and is suitable for slender pancreatic ducts.

Figure 4 The second improved design of the pancreatic stent.

The silicone rubber material ventricular drainage tubes (Nantong Sanli, NS type) commonly used in the operating room were selected. The model was individualized according to the diameter of the pancreatic duct, and the commonly used models included 6-F (2.0 mm), 8-F (2.7 mm), and 10-F (3.3 mm), etc.

The selection between the two surgical approaches was determined by pancreatic duct diameter measurements. Following method selection, a silicone catheter was positioned such that its tapered end extended 3 cm into the pancreatic parenchyma. The flared distal portion of the catheter was then introduced through an appropriately sized enterotomy created in the jejunal wall. A tension-free end-to-side pancreaticojejunal anastomosis was subsequently performed under direct visualization (Figure 5).

Figure 5 The pancreas and jejunum were closely anastomosed end-to-side.

Operative procedure

In this study, the “double purse-string pancreaticojejunostomy through-and-through suture” mucosa-to-mucosa technique was adopted. The specific surgical procedure is as follows (Video 1):

• Step 1: The pancreatic duct stent was inserted approximately 3 cm into the main pancreatic duct and securely fixed using 4-0 Vicryl sutures (ETHICON, Somerville, NJ, USA) to ensure the stability of the stent position.
• Step 2: Above the stent tube, a figure-of-eight suture technique was employed using 3-0 Prolene sutures (ETHICON) to penetrate the pancreatic transection plane and the seromuscular layer of the jejunum. The needle entry point was located approximately 5 mm from the edge of the ventral pancreatic transection margin. The suture then exited from the seromuscular layer of the jejunum, with the stitch interval maintained at 8–10 mm, achieving precise coaptation between the upper margin of the pancreatic duct and the corresponding jejunal incision.
• Step 3: A second figure-of-eight suture was performed below the stent tube. The suture needle entered the pancreatic parenchyma at the upper margin of the stent tube, traversed the pancreatic duct stent, and exited through the jejunal wall beneath it, thereby maintaining the structural integrity of the lower margin of the anastomosis.
• Step 4: At the antimesenteric border of the jejunum, 5 cm away from the jejunal transection end, an opening commensurate with the diameter of the main pancreatic duct was created. The enlarged portion of the pancreatic duct stent was inserted through this opening into the jejunal lumen for approximately 5 cm in the direction of the proximal jejunum. Subsequently, a purse-string suture was carried out using 4-0 Vicryl sutures, with the suture depth reaching the seromuscular layer of the jejunum and the stitch distance controlled at approximately 3 mm, ensuring secure fixation of the stent and effective prevention of fluid leakage.
• Step 5: In the distal region of the stent tube, continuous figure-of-eight sutures were further executed using 3-0 Prolene sutures to gradually approximate the pancreatic transection plane and the jejunal wall below, enhancing the stability of the anastomotic interface.
• Step 6: Finally, the Prolene sutures were tightened and securely knotted on the pancreatic side to ensure uniform stress distribution across the entire anastomosis, thus forming a tight and tension-free pancreaticojejunal anastomosis.

Following a successful anastomosis, the abdominal drainage tube was positioned in a crossed manner posterior to the PJ site.

Postoperative considerations and tasks

Postoperative management included standard protocols: fasting, gastrointestinal decompression, hepatoprotective therapy, enzyme inhibition, anti-infective treatment, acid suppression, and other supportive measures. The amylase level of ascites was monitored on the third and seventh postoperative days and prior to the removal of the abdominal drainage tube.

Furthermore, on the first postoperative day, our surgical team initiated routine continuous peritoneal lavage in accordance with the standard nursing protocol. This approach can dilute the pancreatic juice that leaks into the peritoneal cavity during the early postoperative period, specifically the early stage of POPF, thereby reducing the risk of severe complications. Only when all the above conditions are met can the drainage tube be removed. The speed of abdominal cavity irrigation was adjusted according to the nature of the drainage fluid. If the drainage fluid was turbid or contained flocculent matter, high-flow irrigation was performed until the fluid was clear; if the drainage fluid was clear, low-flow irrigation (20 drops/minute) was used.

Criteria for drainage tube removal

The drainage tube can be removed when the drainage fluid is clear without any foreign substances, the amylase level of ascites returns to normal upon re-examination, and no fluid collection in the drainage area is detected on re-examination of abdominal CT.

Observation target

• General information (gender, age, underlying disease).
• Operation-related information (intraoperative blood loss, postoperative complications, postoperative hospital stay, prognosis).
• Postoperative pathological diagnosis.
• Follow-up results at 3 months after surgery.

Patients underwent PJ collected in this study is shown in Table 1.

Statistical analysis

Statistical analysis was performed using SPSS software, version 24.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation or median (range), and categorical variables were expressed as numbers.

Results

A cohort of 33 patients [18 males, 15 females; mean age 60 (range, 46–75) years] underwent PJ with a novel stent tube. Among the cases included in this study, there were 3 cases (9.1%) with a main pancreatic duct diameter of ≤2 mm, 19 cases (57.6%) with a diameter of 2 to 3 mm, and 11 cases (33.3%) with a diameter of >3 mm. Regarding the texture of the pancreas, 20 cases (60.6%) had a soft texture and 13 cases (39.4%) had a hard texture. The median intraoperative blood loss was 100 (range, 50–700) mL.

Postoperative complications were observed in 16 patients (48.5%). Among them, a total of 5 patients (15.2%) experienced Grade B/C POPF.

The specific types of complications were as follows:

• Grade A POPF (n=11, 33.3%).
• Grade B POPF (n=4, 12.1%), which included 3 cases (9.1%) of delayed gastric emptying (DGE) and 1 case of surgical site infection. DGE refers to a pathological condition in which the rate of gastric contents emptying into the duodenum is significantly decelerated, leading to abnormal gastric emptying and consequently triggering a series of clinical symptoms. Herein, DGE pertains to clinically relevant gastric emptying, specifically: the inability to consume solid food 7 days post-surgery; experiencing severe abdominal distension and vomiting after eating, necessitating the re-insertion of a gastric tube for more than 7 days; or the occurrence of postoperative complications due to gastric emptying impairment; or the requirement for pharmacological intervention.
• Grade C POPF (n=1, 3.0%). The manifestation of Grade C POPF was post-pancreatectomy hemorrhage (PPH), it refers to bleeding in the abdominal cavity or digestive tract caused by various factors such as surgical manipulation, local inflammation, and vascular injury. All complications resolved with appropriate interventions, including peritoneal drainage (n=11), embolization (n=1), and nutritional support (n=3). Notably, no stent-related complications occurred [0%; 95% confidence interval (CI): 0.0–10.6%], such as intestinal perforation or tube dislodgement.

Pathological diagnoses included pancreatic head tumors (n=14, 42.4%), duodenal tumors (n=17, 51.5%), choledochal tumor (n=1, 3.0%), and intraductal papillary mucinous neoplasm (IPMN) (n=1, 3.0%). The median postoperative hospitalization was 15 (range, 12–38) days.

Among the 31 patients (93.9%) who completed the 3-month follow-up, two cases (6.1%) were lost to follow-up. Seven patients (7/31, 22.6%) underwent CT reexamination during the follow-up period, and partial or complete expulsion of the stent tube was observed.

Stent selection

Thirty cases (90.9%) utilized the first type of stent, and three cases (9.1%) employed the second type. Given the limited sample size of the second-type stent, the correlation between stent type and clinical outcomes cannot be analyzed at present. Future research with a larger sample size is required for further verification.

Insertion length within the pancreas

An insertion length of 3 cm was uniformly adopted for all cases, and no control groups with varying lengths were established. Currently, no evident association has been detected between this parameter and POPF.

Discussion

PJ remains a critical component of digestive tract reconstruction in pancreatic surgical procedures. Given its technical complexity and substantial impact on postoperative outcomes, this anastomotic technique has undergone continuous innovation and refinement through various methodological advancements aimed at reducing postoperative complications and optimizing patient prognosis (7-9). Both internal and external pancreatic stents have shown significant efficacy in clinical practice, particularly in safeguarding the integrity of pancreatoenteric anastomosis and reducing POPF rates following pancreatic resections, with current evidence supporting their prophylactic use in high-risk surgical scenarios (10-12). Our team routinely performs PJ with placement of internal stents.

Conventional surgical methods, stent and deficiencies

In the conventional PJ procedure, a standardized approach involves the following technical steps: a Silastic catheter is selected as the pancreatic duct stent based on preoperative measurements of the pancreatic duct diameter. The distal end of the catheter is surgically modified by creating an oblique cross-section with two to three precisely placed lateral fenestrations. Under direct visualization, the prepared catheter is then introduced into the pancreatic duct in a retrograde manner, ensuring that the modified distal segment is secured with a 3-cm intrapancreatic placement. Concurrently, the proximal end of the catheter is carefully routed through an appropriately sized enterotomy created in the jejunal wall, ultimately positioning it within the jejunal lumen. This strategically placed silastic tube subsequently functions as a permanent indwelling stent to maintain anastomotic patency throughout the postoperative period (13) (Figure 6).

Figure 6 Conventional pancreatic stent.

Following stent placement, a precise end-to-side PJ was created using polypropylene (Prolene) sutures. This anastomotic configuration provides robust mechanical integrity while facilitating physiological healing processes. The implanted stent effectively diverts pancreatic secretions into the intestinal lumen, where enzymatic constituents participate in normal digestive functions. This established surgical technique remains the standard approach for anatomical drainage of pancreatic exocrine secretions.

However, conventional pancreaticojejunal anastomosis presents notable limitations. When utilizing stents with small-caliber lumens and rigid structural properties, the combination of postoperative intestinal motility and inherent stent migration tendency may predispose patients to inadvertent intestinal perforation (12). This complication risk becomes particularly significant when stent indwelling duration exceeds recommended parameters.

The utilization of internal stents in PJ procedures presents several clinically significant complications, notably stent occlusion, device migration, and structural deformities of the pancreatic ductal system. These device-related challenges may compromise surgical outcomes through mechanisms such as impaired pancreatic drainage, inflammatory responses to stent material, and secondary fibrosis development (6).

If the selected pancreatic drainage tube is too thin in diameter or excessively rigid in texture, combined with factors such as intestinal peristalsis, its intestinal end may puncture the intestinal wall. This complication can be life-threatening due to the corrosive nature of pancreatic fluid. In addition to cases encountered by our team, there have been reported postoperative complications caused by pancreatic drainage tubes in other clinical cases (14-19). A 75-year-old woman presenting with acute abdominal pain was found to have developed a delayed complication 19 years post-pancreatoduodenectomy. Cross-sectional imaging demonstrated distal migration of the pancreaticojejunal anastomotic stent, ultimately leading to transmural bowel perforation (12). Another case of postoperative duodenal perforation following PD was reported in a 71-year-old female patient (16). Pancreatic stent proximal migration through the anastomotic site complicated by chronic pancreatitis is a potential complication of PJ. A case was reported of a 60-year-old woman who underwent potentially therapeutic pylorus-preserving PD. Four years postoperatively, the patient developed abdominal pain, steatorrhea, and weight loss. CT revealed a stent in the proximal pancreatic duct accompanied by upstream pancreatic duct dilation and parenchymal features of chronic pancreatitis (16). Moreover, several rare complications have been reported in the literature, including migration of a pancreatic stent into the bile duct and small intestinal fistulas associated with pancreaticoenteric stents (17-19).

Therefore, it is very important to select an appropriate pancreatic drainage tube for PJ.

Modified stent tube advantages

The stent tube optimized by our research team demonstrates four significant improvements.

First, the novel bulbous terminal design substantially reduces intestinal perforation risks through two mechanisms: (I) geometric optimization minimizes localized pressure points, and (II) increased contact surface area enables safer interaction with intestinal mucosa when contact occurs.

Second, this structural modification effectively prevents stent migration into pancreatic ducts—a recognized contributor to iatrogenic chronic pancreatitis.

Third, based on the structural design of the improved stent, it is theoretically postulated that it may possess drainage flow equivalent to that of traditional stents and potential anti-obstruction advantages. Nevertheless, these performance advantages have not been verified by bench tests (such as the determination of pressure-flow curves and in vitro obstruction simulation tests). Further dedicated research is required for confirmation.

Fourth, originating from the modification of conventional pipelines in the operating room, which facilitates convenient material access.

Preliminary evidence suggests this optimized design may also facilitate spontaneous stent expulsion during the natural healing process, though this requires prospective clinical validation (Figure 7). During the 3-month follow-up period, a total of 31 patients completed the follow-up (accounting for 93.9% of the total cases), among which 7 cases (7/31, 22.6%) were observed to have partial or complete discharge of stent tubes in the re-examination CT. However, due to the lack of continuous imaging monitoring data, the exact discharge time could not be accurately determined, and thus no statistical analysis was conducted on the discharge time. The subsequent research plan is to extend the follow-up period to further clarify the temporal characteristics of stent tube discharge.

Figure 7 On the 78th day after the operation, the stent tube fell off and entered the anal canal.

Limitation

This study so far has limitations for insufficient follow-up time, unclear long-term complications, and relatively few patients can be adequately analyzed.

Conclusions

Preliminary findings suggest that the optimized pancreatic duct stent exhibits favorable early-stage safety in current clinical applications. No stent-related complications were detected within this cohort. As further research progresses, this improved medical device holds promise for demonstrating broader clinical utility and substantial potential in enhancing patient treatment efficacy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-342/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-342/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-342/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second Affiliated Hospital of Nanchang University (IIT-O-2024-214). Informed consent was waived by the Ethics Committee for this retrospective study due to the exclusive use of de-identified patient data, which posed no potential harm or impact on patient care.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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