A modified stent-free Chen's U-suture technique in pediatric pancreaticojejunostomy: safety and efficacy

Pediatric pancreatic surgery is challenging due to soft pancreatic texture and small main pancreatic duct (MPD) diameter, both risk factors for postoperative pancreatic fistula (POPF). The modified stent-free Chen's U-suture technique, a continuous transpancreatic U-shaped invagination pancreaticojejunostomy without stenting, has shown low clinically relevant POPF (CR-POPF) rates in adults. This study evaluates its safety and feasibility in children.

From July 2018 to November 2025, five children (2 males, 3 females; aged 4.3-10.1 years) underwent pancreatic resection with the modified stent-free Chen's U-suture technique (no MPD stent placement). Diagnoses included pancreatic head solid pseudopapillary neoplasm (SPN, n = 2, one with jaundice), body SPN (n = 1), grade III trauma (n = 1), and complex iatrogenic injury (n = 1). The primary endpoint was POPF rate (ISGPS 2016).

All procedures were successful. Median operative time was 5 h (range 3-8); mean pancreaticojejunostomy time 17.8 min (15-21); median blood loss 50 mL (20-100). Two patients had transient mild hyperamylasemia (< 2×upper limit of normal) with imaging showing localized perianastomotic edema/fluid collection without diffuse parenchymal edema or necrosis, managed conservatively. One patient met the criteria for a biochemical leak; no CR-POPF (0%, 95% CI: 0.0%-52.2%) (grade B/C) occurred. No infection, hemorrhage, reoperation, or readmission occurred. Drains were removed on days 5-14 (median, 7 days). At median 25-month follow-up (range 4-92), one child required pancreatic enzyme replacement for fat malabsorption 4 years post-surgery; no new diabetes or other malabsorption occurred. One patient had asymptomatic mild distal MPD dilatation (2.9 mm) at 25 months; another had normal MPD shape (2.3 mm) at 4 months.

The modified stent-free Chen's U-suture technique demonstrates promising feasiblility and safety for pediatric pancreatic head, neck, or body tumor resection, grade III trauma, and complex iatrogenic injuries, achieving a 0% CR-POPF rate in this small cohort (95% CI: 0.0%-52.2%) without the need for internal stenting. Transient mild hyperamylasemia with localized perianastomotic inflammatory changes is uncommon and manageable. Long-term pancreatic function is generally preserved, though asymptomatic MPD dilatation may occur.