Modified Blumgart versus modified Heidelberg technique for pancreatic anastomosis in pancreaticoduodenectomy, which is more effective?

Introduction
Leakage from pancreatic anastomosis is the main cause of postoperative mortality and morbidity after pancreaticoduodenectomy (PD). Advanced studies suggested Blumgart anastomosis (BA) and modified BA (m-BA) as a technique that may minimize major complications after PD. This study compares m-BA with modified Heidelberg anastomosis (m-HA) for pancreaticojejunostomy (PJ) after PD as a single-center experience.
Methods
A total of 46 patients who underwent PD at Ain Shams University Hospitals between January 2021 and February 2023 were enrolled in this research. The patients were categorized into two groups according to the anastomosis type. 24 patients underwent anastomosis using m-BA (group A) and 22 patients underwent anastomosis using m-HA (group B). The primary outcome is postoperative pancreatic fistula (POPF), bleeding, and mortality. The secondary outcome is the duration of the procedure, the number of sutures used, and other complications.
Results
The demographic and all preoperative data were insignificantly different between both groups. The operative time was significantly less in m-BA group as the time of the pancreatic anastomosis was significantly lower (21.08±3.5 min) in comparison to m-HA (69.32±8.4 min) value less than 0.001. The polydioxanone suture (PDS) threads consumed were significantly less in m-BA in comparison to m-HA (median (IQR) 9 (9–9) and 28 (26–30), respectively, value < 0.001) POPF was less in the m-BA group than m-HA (16.7 and 31.8%, respectively, value 0.229) and postpancreatectomy hemorrhage (16.7% and 22.7%, respectively, value 0.609), and the POPF in the soft pancreas was much less in m-BA (10% and 50%, respectively, value 0.051), although statistically insignificant but it is clinically significant.
Conclusion
The m-BA technique can provide a better solution for pancreatic remnant management with less POPF, especially in soft pancreas with high fistula risk score, however, a small sample size may be the cause of the statistically insignificant difference, so larger studies are required. Nevertheless, m-BA consumes a lower number of PDS sutures with much lower cost and also less operative time.