Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy

Background: Postoperative pancreatic fistula (POPF) is a major complication followingpancreaticoduodenectomy (PD) and is often associated with delayed recovery and postoperative 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. Methods: 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. Results: Among 229 patients who underwent PD with the FIT, the median amylase concentration on postoperative day (POD) 3 was significantly lower in the hepaticojejunostomy (HJ) drain compared with the PJ drain (74 vs. 255 IU/L, p < 0.001). In the subgroup of 102 patients who developed POPF; Grades biochemical leak [BL], B, or C), the median POD 3 amylase concentration in the HJ drain remained significantly lower than that in the PJ drain (233 vs. 1,619 IU/L, p < 0.001), confirming effective compartmentalization of the drainage spaces. Among patients with Grade B POPF, 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. Postpancreatectomy hemorrhage (PPH) originating from the gastroduodenal artery (GDA) stump occurred in two patients (0.9%). Conclusions: This compartmentalization strategy yielded three major clinical advantages: 1. Early drain removal and simplified single-drain care 2. Localized control and safer interventionl —allowing efficient infection control, and 3. Structural protection of major arteries —reducing arterial exposure to pancreatic enzymes and thereby minimizing the risk of PPH from the GDA stump. The consistently marked amylase gradient observed between the PJ and HJ drains provides quantitative evidence that FIT promotes effective physiological separation, ensuring predictable drainage behavior and a safer postoperative environment. Collectively, these findings support FIT as a practical, physiologically sound, and structurally rational approach for postoperative management following PD.