Hepatopancreatoduodenectomy With Delayed Division of the Pancreatic Parenchyma: A Novel Technique for Reducing Pancreatic Fistula

OBJECTIVES: To review our novel technique of hepatopancreatoduodenectomy (HPD) with delayed division of the pancreatic parenchyma (DDPP) for reducing postoperative pancreatic fistula (POPF). BACKGROUND: The high operative morbidity and mortality rates after HPD remains a major issue. One of the most troublesome complications is POPF, which might possibly be caused by peripancreatic saponification due to long interval between pancreas resection and reconstruction, as most surgeons prefer a caudocranial approach, performing pancreatoduodenectomy (PD) first and then hepatectomy (conventional HPD [C-HPD]). METHODS: A review of the patients undergoing C-HPD and HPD with DDPP was performed. Postoperative outcomes were compared. Multivariable analysis was conducted to evaluate the risk factors of POPF after HPD. RESULTS: One-hundred two patients comprised of 50 patients undergoing C-HPD and 52 patients undergoing HPD with DDPP. The interval between pancreas resection and reconstruction was significantly shorter in HPD with DDPP group than in C-HPD group (51 vs 263 minutes; P < 0.001). The incidence of POPF was significantly lower in HPD with DDPP group than in C-HPD group (32.7% vs 77.3%; P < 0.001). The postoperative hospital stay was shorter in patients undergoing HPD with DDPP than in those undergoing C-HPD (32 vs 45 days). A multivariate analysis revealed that body mass index >24 kg/m(2) and conventional (PD first) procedure were significant risk factors for POPF after HPD. CONCLUSIONS: A novel technique of HPD with DDPP is a simple procedure and the optimal treatment choice to reduce the risk of developing POPF after this extensive surgery.