Comment on “Main pancreatic duct exposure, repair, or reconstruction during minimally invasive pancreatic enucleation: a long-term metabolic outcome from a prospective cohort study (CSPAC-MIEN-1)”: a classification method for pancreatic surgery cente

Dear Editor, We read with great interest the article by Li et al, “Main pancreatic duct exposure, repair, or reconstruction during minimally invasive pancreatic enucleation: a long-term metabolic outcome from a prospective cohort study (CSPAC-MIEN-1)”[1]. This study investigates the impact of main pancreatic duct (MPD) exposure, repair, or reconstruction during minimally invasive enucleation on long-term metabolic outcomes and quality of life (QoL) in patients. The results show that while MPD repair or reconstruction significantly increases perioperative complications, it does not affect long-term pancreatic endocrine and exocrine functions or patient QoL. This study also provides a solution for managing intraoperative pancreatic duct injuries. The traditional view holds that the MPD is difficult to repair functionally once injured or transected during surgery. In recent years, increasing evidence from research has shown that meticulous reconstruction of the MPD is feasible[2-6]. We hereby propose the “Zhu Classification,” a novel framework for categorizing pancreatic duct injuries based on intraoperative assessment and guiding real-time decision-making. Unlike existing classifications, which predominantly focus on anatomical regions or tumor types, the Zhu Classification centers on the extent of pancreatic duct injury observed during surgery. This allows for a more tailored approach to treatment, with an emphasis on personalized management and dynamic decision-making. The Zhu Classification divides pancreatic duct injury into four main types (Fig. 1): Figure 1.: The classification system based on intraoperative pancreatic duct injury. Type 0: Absence of any remaining pancreatic duct. Definition: When performing a total pancreatectomy, if there is no pancreatic duct structure postoperatively, this is referred to as the “no pancreatic duct type.” Management: No specific treatment is required. Type I: Partial damaged pancreatic duct. Definition: When a pancreatic tumor is near or adheres closely to the MPD, resection of the tumor will damage part of the MPD, but the duct remains continuous overall. This is referred to as the “partial damage to the pancreatic duct” type. Management: When the damage to the MPD is minimal, we can attempt an end-to-end anastomosis of the pancreatic duct, followed by suturing the pancreatic wound edges together. This approach is similar to the repair concept described in Li’s article[1]. When the damage to the MPD is more extensive, we can select an appropriately sized pancreatic duct support tube intraoperatively to ensure the smooth flow of pancreatic juice, followed by suturing the pancreatic wound edges together. This approach is similar to the pancreatic duct reconstruction concept described in Li’s article[1]. Type II: Intact and continuous pancreatic duct. Definition: When the pancreatic tumor is distant from the MPD (usually considered ≥2 mm) or located on the body-tail side of the pancreas, resection of the tumor requires a pancreatic enucleation or distal pancreatectomy. Postoperatively, the pancreatic duct remains continuous. This is referred to as the “intact and continuous pancreatic duct” type. When performing enucleation, it is called the “complete pancreatic duct” type (Type IIa). When performing distal pancreatectomy, it is called the “body-tail closure” type (Type IIb). Management: Adequate hemostasis should be achieved at the pancreatic wound during surgery, and branch pancreatic ducts should be carefully ligated. Type III: Disrupted pancreatic duct. Definition: When performing pancreatic enucleation, pancreatic body segment resection, traditional pancreatoduodenectomy, or pancreatic head resection with preservation of the duodenum, if the MPD is completely transected intraoperatively, this is referred to as the “pancreatic duct interruption” type. When the interruption distance is ≤1.5 cm, it is called the “narrow interruption” type (Type IIIa); when the interruption distance is >1.5 cm, it is called the “wide interruption” type (Type IIIb); when performing pancreatic head resection, it is called the “head-side interruption” type (Type IIIc). Management: Based on personal clinical practice, we recommend that Type IIIa can be treated with pancreatic duct reconstruction (the main criterion for determining whether duct reconstruction is feasible is the tension produced when suturing the pancreatic wound edges together; Liu’s study advocates for mobilizing the distal pancreas to increase the available distance[7]). For Types IIIb and IIIc, pancreatic reconstruction is performed, i.e., traditional pancreaticojejunostomy or pancreatogastrostomy. In summary, the Zhu classification system summarizes and categorizes the postoperative status of the pancreas and the management of the subsequent pancreatic remnant. Its core value lies in systematizing the real-time assessment and repair strategies for intraoperative pancreatic duct injuries, enabling surgeons to choose the optimal approach during surgery based on the specific nature of the duct injury. This correspondence adheres to the TITAN 2025 guideline for transparency and integrity in translational and applied research[8]. No artificial intelligence tools were used in this correspondence.