The Hidden Architecture of Pancreatic Ducts: 3D Anatomical Reconstruction and Its Implication on Pancreatic Resection

BACKGROUND/PURPOSE: Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery and its mechanisms remain incompletely understood. While the diameter of the main pancreatic duct is well-known to be a risk factor of POPF, the impact of branch duct's (BD) anatomy is not known. METHODS: All consecutive pancreas procured from body donations were prospectively studied between March 2024 and March 2025. After total pancreatectomy, the main pancreatic and accessory ducts, when present, were cannulated and injected with polymerizable resin. Tissue corrosion using potassium hydroxide produced detailed 3D casts. BD were analyzed according to number, order, and angulation. RESULTS: Thirty 3D casts were analyzed from donors. The median number of BD was 96 ± 27, including 45 ± 8 first-order BD. Pancreatic heads exhibited the highest number of BD, while the isthmus showed the fewest (p < 0.001). Mean angulation increased progressively from 74° ± 14° in the isthmus to 81° ± 12° in the tail (p = 0.351). Ductal bifurcation of the main pancreatic duct at the corporeocaudal junction was present in 17%. The cephalic and uncinate regions displayed the most complex networks and included long ascending and descending branches. CONCLUSIONS: Pancreatic ductal network shows substantial regional variability, which may partly explain differences in POPF risk according to the transection site.