The Mismatch Point: A Modified Technique to Prevent and Overcome Duct-Enterotomy Discrepancy in High-Risk...

Anastomotic failure remains the leading source of morbidity after pancreatoduodenectomy, particularly in patients with a soft pancreas and a small main pancreatic duct. In this high-risk setting, reconstruction is frequently compromised by geometric mismatch between the duct and an oversized jejunal enterotomy, as well as by eccentric duct anatomy that limits safe circumferential suturing. Conventional duct-to-mucosa techniques rely on tissue traction and precise stitch placement, which may be mechanically unstable in fragile glands. We developed a Seldinger-inspired, stent-centered pancreaticojejunostomy designed to address these limitations through geometry preservation and structural stabilization. Instead of cutting the jejunum, the enterotomy is created by controlled puncture and sequential dilation. A biodegradable intraductal stent is introduced over a guidewire, establishing duct-jejunal coaxial alignment. External stabilization is achieved using Blumgart-based fixation and serosal-capsular closure, avoiding ductal traction and circumferential duct-to-mucosa suturing. This technique was applied in a consecutive feasibility series of 15 high-risk patients (soft pancreas and main duct ≤ 3 mm) undergoing minimally invasive pancreatoduodenectomy. The procedure was completed robotically in 14 cases and laparoscopically in one, with no conversions or intraoperative complications. Biochemical pancreatic fistula occurred in 3 patients (20%), with no clinically relevant fistulas. No major complications (Clavien-Dindo ≥ III) or 90-day mortality were observed. By transforming a fragile duct-bowel interface into a geometry- and structure-supported reconstruction, this approach appears technically feasible and associated with encouraging short-term safety signals in a highly selected high-risk cohort. These findings should be interpreted as preliminary feasibility data and require validation in larger, multi-operator series.