Falciform ligament interposition technique: an optimized drainage strategy after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a major complication following pancreaticoduodenectomy (PD) and is often associated with delayed recovery and postpancreatectomy hemorrhage (PPH). The falciform ligament interposition technique (FIT) employs the falciform ligament as a vascularized flap positioned between the pancreaticojejunostomy (PJ) and the hepatic artery. This approach provides a mechanical barrier and enables functional separation of the drainage spaces, potentially reducing the risk of POPF-related PPH. This study aimed to evaluate the reproducibility of functional drainage compartmentalization achieved by FIT. This retrospective study included all consecutive patients who underwent PD at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan) between January 2018 and June 2024. Postoperative outcomes, including drain-related variables, incidence of POPF, and occurrence of PPH, were systematically analyzed. Among 102 patients who developed POPF; Grades biochemical leak [BL], B, or C), the median POD 3 amylase concentration in the HJ drain was significantly lower than that in the PJ drain (233 vs. 1,619 IU/L, p < 0.001), confirming effective compartmentalization of the drainage spaces. In the Grade BL and B POPF cohorts, the median durations of drain placement were 23 days for the Area PJ drain and 7 days for the Area HJ drain (p < 0.001) (Fig. 4B). In the Grade B POPF cohort, 24 (49.0%) required additional percutaneous drainage, which was safely and easily performed via the anterior abdominal wall because the fluid collection was confined to the PJ site immediately beneath it. PPH associated with pseudoaneurysm formation at the gastroduodenal artery stump occurred in two patients (0.9%). The consistent amylase gradient observed after the addition of FIT provides quantitative evidence of effective physiological separation between the two drainage compartments. FIT allows earlier removal of the HJ drain relative to the PJ drain. Other intended effects, including localization of pancreatic leakage to the anterior PJ compartment and structural isolation of major arterial stumps from pancreatic juice exposure, require further investigation in future comparative studies.