Geometric simplification by ductal unification of dual pancreatic ducts during pancreaticojejunostomy

Anatomical variations of the pancreatic duct are common; however, two closely approximated ductal lumens at the margin of pancreatic transection present a distinct reconstructive challenge during pancreaticoduodenectomy (PD). When the inter-ductal distance is minimal, conventional assumptions underlying pancreaticojejunostomy may not apply. In this two-case report, two patients undergoing PD were preoperatively diagnosed with dual pancreatic ducts by contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography. Histopathological assessment demonstrated minimal inter-ductal distances (3.05 mm and 0.35 mm) at the transection margin in each patient. Separate duct-to-mucosa anastomoses were considered technically unfavorable because the pancreatic parenchymal cuffs were too small to allow secure suturing and because of the risk of ischemia in the narrow intervening pancreatic bridge. Therefore, a ductal unification strategy was adopted. The septum between the ducts was sealed using an ultrasonic device, divided under hemostatic control, and sutured to create a single ductal orifice. Standard duct-to-mucosa pancreaticojejunostomy was then performed within the Blumgart framework. Both patients had uneventful postoperative courses without clinically relevant postoperative pancreatic fistulae. Ductal unification may represent a feasible technical option in carefully selected cases of closely approximated dual pancreatic ducts, but further experience is required before any recommendation can be made.