• Charlson comorbidity index
• distal pancreatectomy
• postoperative pancreatic fistula

• Humans
• Pancreatic Fistula/epidemiology
• Pancreatic Fistula/etiology
• Male
• Female
• Retrospective Studies
• Pancreaticoduodenectomy/adverse effects
• Middle Aged
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Pancreatectomy/adverse effects
• Aged
• Comorbidity
• Risk Factors
• Risk Assessment
• Adult

• Machine learning
• Pancreatoduodenectomy
• Postoperative pancreatic fistula
• Precision oncology
• Risk factors

• Prognostic nutritional index
• biochemical leak
• postoperative pancreatic fistula

• Humans
• Male
• Female
• Pancreaticoduodenectomy/adverse effects
• Pancreatic Fistula/etiology
• Retrospective Studies
• Risk Factors
• Middle Aged
• Disease Progression
• Aged
• Postoperative Complications/etiology
• Prognosis
• Nutrition Assessment
• ROC Curve
• Anastomotic Leak/etiology
• Adult

• Anastomotic leak (AL)
• bile leak (BL)
• grading systems
• hepato-pancreato-biliary (HPB)
• postoperative pancreatic fistula (POPF)

• drain amylase concentration
• gastric cancer
• minimally invasive surgery
• pancreas compression
• postoperative complications

• Pancreatoduodenectomy
• Postoperative pancreatic fistula
• Preoperative risk calculation

• Delayed gastric emptying
• Meta-analysis
• Pancreatic fistula
• Pancreaticoduodenectomy
• Pancreaticogastrostomy
• Pancreaticojejunostomy

• Gastrostomy/adverse effects
• Humans
• Pancreatic Fistula/epidemiology
• Pancreatic Fistula/etiology
• Pancreaticoduodenectomy/adverse effects
• Pancreaticojejunostomy/adverse effects
• Postoperative Complications/etiology
• Prognosis
• Randomized Controlled Trials as Topic

• 81660398 National Natural Science Foundation of China
• 19SYPYA-12 Hospital Key Program of National Scientific Research Cultivation Plan

and Importance: Post-operative pancreatic fistula is a morbid complication after pancreaticoduodenectomy. Though most of them present in the immediate post-operative period, few case reports have mentioned it even 7 years after index surgery. Here, we report a delayed presentation of pancreatic fistula 6 months after surgery.

A 57 year old female underwent Whipple's pancreaticoduodenectomy for pancreatic head adenocarcinoma and was discharged with an uneventful post-operative recovery. She presented after 6 months with complaints of abdominal pain and distension which upon evaluation was found to be a pancreatic enzyme rich mutiloculated collection. It was managed with per-cutaneous drain placement.

Pancreatic fistula remained a major cause of morbidity and mortality even after 100 years of its existence. It can be overt fistula which manifest in the immediate post-operative period or occult fistula which manifests long after primary surgery. Various causes of delayed fistula are anastomotic site stricture, previous chemotherapy, infection. The management options available are percutaneous drainage, endoscopic stenting of anastomotic stricture or redoing the anastomosis.

Pancreatic fistula can have a delayed presentation which can be diagnosed and managed with regular follow up.

•

POPF is a morbid complication following PD.

• Endoscopic stenting
• Occult pancreatic fistula
• Overt pancreatic fistula pancreaticoduodenectomy
• Percutaneous drainage
• Post-operative pancreatic fistula

• Case report
• Disconnected pancreatic duct syndrome
• External drainage
• Internal drainage
• Pancreatic leakage
• Surgery
• Systemic inflammatory response syndrome

• Drainage
• Female
• Humans
• Middle Aged
• Pancreatic Ducts/surgery
• Pancreatic Fistula/etiology
• Pancreatic Fistula/surgery
• Pancreaticojejunostomy
• Retrospective Studies
• Treatment Outcome

• duct to mucosa anastomosis
• dunking anastomosis
• intra-hospital stay
• mortality
• pancreatic head carcinoma
• pancreaticoduodenectomy
• postoperative pancreatic fistula

Pancreaticoduodenectomy is a technically demanding operation, with reported morbidity rates of approximately 40%–50%. A novel idea is to use endoscopic vacuum therapy (EVT) in a preemptive setting to prevent anastomotic leakage and pancreatic fistulas. In a recent case series, EVT was proven to be effective in preventing leaks in patients with anastomotic ischemia. There have been no previous reports on preemptive EVT after pancreaticoduodenectomy.

We describe the case of a 71-year-old woman with hypertension and diabetes who was admitted to the emergency room with jaundice, choluria, fecal acholia, abdominal pain, and fever. Admission examinations revealed leukocytosis and hyperbilirubinemia (total: 13 mg/dL; conjugated: 12.1 mg/dL). Abdominal ultrasound showed cholelithiasis and dilation of the common bile duct. Magnetic resonance imaging demonstrated a stenotic area, and a biopsy confirmed cholangiocarcinoma. Considering the high risk of leaks after pancreaticoduodenectomy, preemptive endoluminal vacuum therapy was performed. The system comprised a nasogastric tube, gauze, and an antimicrobial incise drape. The negative pressure was 125 mmHg, and no adverse events occurred. The patient was discharged on postoperative day 5 without any symptoms.

Preemptive endoluminal vacuum therapy may be a safe and feasible technique to reduce leaks after pancreaticoduodenectomy.

• Preemptive
• Endoluminal
• Vacuum
• Pancreaticoduodenectomy
• Case report

• CONUT
• pancreatic fistula
• pancreaticoduodenectomy

• Aged
• Female
• Humans
• Male
• Nutrition Assessment
• Nutritional Status
• Pancreatectomy
• Pancreatic Fistula/diagnosis
• Pancreatic Fistula/etiology
• Pancreaticoduodenectomy/adverse effects
• Postoperative Complications/etiology
• Retrospective Studies
• Risk Factors

Pancreaticoduodenectomy (the Whipple procedure) is the only potential curative treatment for periampullary tumours. Although mortality due to the procedure is gradually decreasing, the morbidity rates remain high. This study aimed to evaluate early computed tomography (CT) findings in patients suspected of complications following the Whipple procedure.

The CT images of patients who underwent the conventional Whipple procedure between January 2015 and January 2019 and underwent CT examination for the detection of early postoperative complications were retrospectively evaluated by two radiologists.

The Whipple operation was performed to 65 patients, and the CT scans of 45 patients (30 males, 15 females) were included in the study. There were no complications in 21 patients. Complications were present in 24 patients (53.33%), of whom 13 had more than one complication. Eight patients had fluid collection in the operation site, two had haematoma, 10 had an abscess, and five had a pancreatic fistula. In addition, a hepatic abscess was detected in one patient, delayed gastric emptying in six patients, anastomotic leakage from the gastrojejunostomy line in two patients, superior mesenteric vein (SMV) thrombosis in two patients, and intraluminal haemorrhage and active extravasation in one patient. Mortality due to complications occurred in one patient in the early postoperative period. Other complications were treated by spontaneous, surgical or percutaneous interventional procedures.

Despite the decreasing mortality rates in recent years, the Whipple procedure is risky and has high morbidity even when performed in experienced centres. CT is the adequate imaging modality for the evaluation of this anatomically altered region and detection of complications.

• Whipple procedure
• complications
• computed tomography

• Computed tomography
• Hepatic infarction
• PV penetrating sign
• Pancreatoduodenectomy

• distal pancreatectomy
• laparoscopic
• open
• pancreas
• stump closure
• technique

• fibrosis
• pancreas texture
• pancreatic stellate cells
• penicillin G
• postoperative pancreatic fistula (POPF)
• transforming growth factor-β1

• Animals
• Anti-Bacterial Agents/administration & dosage
• Benzamides/pharmacology
• Digestive System Surgical Procedures/adverse effects
• Dioxoles/pharmacology
• Disease Models, Animal
• Fibrosis
• Humans
• Male
• Matrix Metalloproteinase 2/metabolism
• Mice
• Mice, Inbred BALB C
• Pancreas/drug effects
• Pancreas/surgery
• Pancreatic Fistula/etiology
• Pancreatic Fistula/prevention & control
• Pancreatic Stellate Cells/drug effects
• Pancreatic Stellate Cells/metabolism
• Penicillin G/administration & dosage
• Postoperative Complications/prevention & control
• Postoperative Period
• Receptors, Transforming Growth Factor beta/antagonists & inhibitors
• Transforming Growth Factor beta1/metabolism

• NRF-2015R1D1A1A02062336 National Research Foundation of Korea
• NRF-2018R1C1B6002932 National Research Foundation of Korea
• KN19-23 Korea Research Institute of Chemical Technology

To evaluate the effectiveness of computed tomography (CT) Hounsfield unit histogram analysis (HUHA) in postoperative pancreatic fistula (PF) prediction.

Fifty-four patients (33 males and 21 females; mean age, 65.6 years; age range, 37–89 years) who had undergone preoperative CT and pancreaticoduodenectomy were included in this retrospective study. Two radiologists measured mean CT Hounsfield unit (CTHU) values by drawing regions of interest (ROIs) at the level of the pancreaticojejunostomy site on preoperative pre-contrast images. The HUHA values were arbitrarily divided into three categories, comprising HUHA-A ≤ 0 HU, 0 HU < HUHA-B < 30 HU, and HUHA-C ≥ 30 HU. Each HUHA value within the ROI was calculated as a percentage of the entire area using commercial 3-dimensional analysis software. Pancreas texture was evaluated as soft or hard by manual palpation.

Fifteen patients (27.8%) had clinically relevant PFs. The PF group had significantly higher HUHA-A (p < 0.01) and significantly lower mean CTHU (p < 0.01) values than those of the non-PF group. The HUHA-A value had a moderately strong correlation with PF occurrence (r = 0.60, p < 0.01), whereas the mean CTHU had a weak negative correlation with PF occurrence (r = −0.27, p < 0.01). The HUHA-A and mean CTHU areas under the curve (AUCs) for predicting PF occurrence were 0.86 and 0.65, respectively, with significant difference (p < 0.01). The HUHA-A and mean CTHU AUCs for predicting pancreatic softness were 0.86 and 0.64, respectively, with significant difference (p < 0.01).

The HUHA-A values on preoperative pre-contrast CT images demonstrate a strong correlation with PF occurrence.

• Attenuation
• Histogram analysis
• MDCT
• Pancreatic fistula
• Pancreatic softness
• Pancreaticoduodenectomy

The aim of this retrospective study was thus to evaluate postoperative morphological changes in the remnant pancreas after pancreaticoduodenectomy (PD) associated with postoperative pancreatic fistula (POPF). Fifty-one patients subjected to PD were enrolled in the study and allocated into 2 groups according to the presence (n = 16) or absence of POPF (n = 35). A morphological evaluation of the pancreas was conducted for up to a 20 months follow-up on CT scans and compared between groups. No significant differences were observed in morphology between the groups at the different preoperative and PO intervals, regardless of the clinical relevance of the POPF or POPF grade. However, in the overall patient analysis we observed a significant reduction of the entire pancreas over time. In fact, thickness decreased 0.4 mm/month, length 1.2 mm/month and volume 1.17 cm³/month over the PO. The impact of age, POPF, type of anastomosis, surgical technique and PO follow-up (time) was evaluated in a multivariate analysis using the general linear model, but only PO follow-up had a significant influence on the final model (p < 0.001). A significant reduction on pancreatic parenchyma (thickness, length and volume) occurs after PD with no significant differences between patients with or without POPF.

There is little evidence on the safety and benefits of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients; therefore, we evaluated the feasibility and efficacy of this procedure by comparing perioperative and oncological outcomes between LPD and open pancreaticoduodenectomy (OPD) in elderly patients. We retrospectively reviewed the data of 1,693 patients who underwent PD to manage periampullary tumours at a single institution between January 2014 and June 2017. Of these patients, 326 were elderly patients aged ≥70 years, with 56 patients allocated to the LPD group and 270 to the OPD group. One-to-one propensity score matching (56:56) was used to match the baseline characteristics of patients who underwent LPD and OPD. LPD was associated with significantly fewer clinically significant postoperative pancreatic fistulas (7.1% vs. 21.4%), fewer analgesic injections (10 vs. 15.6 times; p = 0.022), and longer operative time (321.8 vs. 268.5 minutes; p = 0.001) than OPD in elderly patients. There were no significant differences in 3-year overall and disease-free survival rates between the LPD and OPD groups. LPD had acceptable perioperative and oncological outcomes compared with OPD in elderly patients. LPD is a reliable treatment option for elderly patients with periampullary tumours.

• Distal pancreatectomy
• Enhanced recovery after surgery
• Pancreatic fistula
• Pancreatoduodenectomy

•

Pancreaticojejunostomy is commonly used in the reconstruction after pancreaticoduodenectomy, but the incidence of POPF remains high.

The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD).

Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality.

Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p =  0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p =  0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p =  0.001).

The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.

• Isolated Roux loop
• Pancreatic fistula
• Pancreaticoduodenectomy
• Pancreaticojejunostomy

• Fluid balance
• Pancreaticoduodenectomy
• Postoperative pancreatic fistula
• Whipple

• Aged
• Female
• Fluid Therapy/adverse effects
• Humans
• Male
• Middle Aged
• Multivariate Analysis
• Pancreatic Fistula/etiology
• Pancreatic Fistula/prevention & control
• Pancreaticoduodenectomy/adverse effects
• Postoperative Complications/etiology
• Retrospective Studies
• Risk Factors
• Water-Electrolyte Balance

• Complications
• Pancreas cancer
• Pancreatic fistula
• Pancreaticoduodenectomy
• Smoking
• Tobacco

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis.

• Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%).

• Multidetector CT is the mainstay technique to investigate suspected complications following PD.

• Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings.

• CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula.

• Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

• Complications
• Computed tomography (CT)
• Pancreatic carcinoma
• Pancreatic fistula
• Pancreatico-duodenectomy

The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection.

In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien–Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors.

In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2.

High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.

• complications
• impact factors
• pancreatic resections

• Complication
• Computed tomography
• Late postpancreatectomy hemorrhage
• Whipple surgery

(1) To illustrate and describe the main types of pancreatic surgery; (2) to discuss the normal findings after pancreatic surgery; (3) to review the main complications and their radiological findings.

Despite the decreased postoperative mortality, morbidity still remains high resulting in longer hospitalisations and greater costs. Imaging findings following major pancreatic resections can be broadly divided into “normal postoperative alterations” and real complications. The former should regress within a few months whereas complications may be life-threatening and should be promptly identified and treated.

CT is the most effective postoperative imaging technique. MRI and fluoroscopy are used less often and only in specific cases such as assessing the gastro-intestinal function or the biliary tree. The most common normal postoperative findings are pneumobilia, perivascular cuffing, fluid collections, lymphadenopathy, acute anastomotic oedema and stranding of the peri-pancreatic/mesenteric fat. Imaging depicts the anastomoses and the new postoperative anatomy. It can also demonstrate early and late complications: pancreatic fistula, haemorrhage, delayed gastric emptying, hepatic infarction, acute pancreatitis of the remnant, porto-mesenteric thrombosis, abscess, biliary anastomotic leaks, anastomotic stenosis and local recurrence.

Radiologists should be aware of surgical procedures, postoperative anatomy and normal postoperative imaging findings to better detect complications and recurrent disease.

• Morbidity after pancreatic resections is high.

• CT is the most effective postoperative imaging technique.

• Imaging depicts the anastomoses and the new postoperative anatomy.

• Pancreatic fistula is the most common complication after partial pancreatic resection.

• Pancreas
• Pancreatectomy
• Pancreaticoduodenectomy
• Pancreaticojejunostomy
• Postoperative complications

• Computed tomography
• Diagnostic imaging
• Pancreatectomy
• Pancreatic ductal adenocarcinoma
• Pancreaticoduodenectomy
• Post-operative complications

• Adenocarcinoma/diagnostic imaging
• Adenocarcinoma/surgery
• Carcinoma, Pancreatic Ductal/diagnostic imaging
• Carcinoma, Pancreatic Ductal/surgery
• Contrast Media
• Humans
• Imaging, Three-Dimensional
• Magnetic Resonance Imaging/methods
• Pancreatectomy
• Pancreatic Neoplasms/diagnostic imaging
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy
• Postoperative Complications/diagnostic imaging
• Tomography, X-Ray Computed/methods

• Fibrosis
• Pancreatic fistula
• Pancreaticoduodenectomy

•

Pancreatic-duodenal injuries are rare.

Combined pancreatic-duodenal injuries in blunt abdominal trauma are rare. These injuries are associated with high morbidity and mortality, and their emergent management is a challenge.

We report a case of combined complete pancreatic (through the neck) and duodenal (first part) transections in a 24-year-old male secondary to blunt abdominal trauma following a motor vehicle crash. The duodenal stumps were closed separately and a gastrojejunostomy performed for intestinal continuity. The transacted head of pancreas main duct was suture ligated and parenchyma was over sewn and buttressed with omentum. The edge of the body and tail pancreatic segment was freshened and an end to side pancreatico-jejunostomy was fashioned. A drain was left in situ. Post operatively the patient developed a pancreatic fistula which resolved with conservative management. After ten months of follow up the patient was well and showed no signs and symptoms of pancreatic insufficiency.

Lengthy, complex procedures in pancreatic injuries have been associated with poor outcomes. Distal pancreatectomy or Whipple’s procedure for trauma are viable options for complete pancreatic transections. But when there is concern that the residual proximal pancreatic tissue is inadequate to provide endocrine or exocrine function, preservation of the pancreatic tissue distal to the injury becomes an option.

Combined pancreatic and duodenal injuries are rare and often fatal. Early identification, resuscitation and surgical intervention is warranted. Because of the large number of possible combinations of injuries to the pancreas and duodenum, no one form of therapy is appropriate for all patients.

• Case report
• Duodenum
• Pancreas
• Trauma

A meta-analysis was conducted in order to provide an up-to-date comparison of pancreatogastrostomy (PG) and pancreatojejunostomy (PJ), after pancreatoduodenectomy (PD), in terms of clinically significant postoperative pancreatic fistula (POPF) and other postoperative complications.

This meta-analysis was conducted according to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature search in MEDLINE and Cochrane Central Register of Controlled Clinical Trials was performed. Fixed Effects or Random Effects model was used, based on the Cochran Q test.

In total, 10 studies (1629 patients) were included. There was no statistical significance between PG and PJ regarding the rate of clinically significant POPF (OR: 0.70, 95%CI: 0.46–1.06). PG was associated with a higher rate of postpancreatoduodenectomy haemorrhage (PPH) (OR: 1.52, 95%CI: 1.08–2.14). There was no difference between the two techniques in terms of clinically significant PPH (OR: 1.35, 95%CI: 0.95–1.93) and clinically significant postoperative delayed gastric emptying (DGE) (OR: 0.98, 95%CI: 0.59–1.63).

There is no difference between the two anastomotic techniques regarding the rate of clinically significant POPF. Given several limitations, more large scale high quality RCTs are required.

• anatomy
• artery
• computed tomography angiography
• pancreas
• pancreaticoduodenectomy

The morbidity rate after pancreaticoduodenectomy remains high. The objectives of this retrospective cohort study were to clarify the risk factors associated with serious morbidity (Clavien–Dindo classification grades IV–V), and create complication risk calculators using the Japanese National Clinical Database.

Between 2011 and 2012, data from 17,564 patients who underwent pancreaticoduodenectomy at 1,311 institutions in Japan were recorded in this database. The morbidity rate and associated risk factors were analyzed.

The overall and serious morbidity rates were 41.6% and 4.5%, respectively. A pancreatic fistula (PF) with an International Study Group of Pancreatic Fistula (ISGPF) grade C was significantly associated with serious morbidity (P < 0.001). Twenty‐one variables were considered statistically significant predictors of serious complications, and 15 of them overlapped with those of a PF with ISGPF grade C. The predictors included age, sex, obesity, functional status, smoking status, the presence of a comorbidity, non‐pancreatic cancer, combined vascular resection, and several abnormal laboratory results. C‐indices of the risk models for serious morbidity and grade C PF were 0.708 and 0.700, respectively.

Preventing a PF grade C is important for decreasing the serious morbidity rate and these risk calculations contribute to adequate patient selection.

• Pancreaticoduodenectomy
• Postoperative complications
• Risk calculator

Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.

• Pancreaticoduodenectomy
• Pancreaticojejunostomy
• Surgical anastomosis

• nutrition
• pancreatic neoplasms
• prealbumin
• surgical outcomes

We evaluated the efficacy of ultrasonography (US) in the early postoperative period after pancreaticoduodenectomy (PD) to diagnose postoperative-pancreatic-fistula (POPF). Early diagnosis is important to prevent POPF-dependent mortality after PD. The value of radiological modalities for early diagnosing POPF is not clear.

Forty-five patients who underwent transabdominal-US in the first postoperative week after PD were retrospectively evaluated. Two types of grouping methods were performed. Firstly, peripancreatic or perianastomotic fluid collections at least 2 cm in diameter were considered to be a primary positive result on US. Patients then divided into 2 groups: group 1, US-positive and group 2, US-negative. Secondly, to increase the power of US, in addition to primary positive results, the presence of fever, leukocytosis or hyperamylasemia was considered to be a secondary positive result (group 1S). The remaining patients were considered to have secondary negative results (group 2S). The sensitivity and specificity for both grouping methods were calculated for the diagnosis of PF and clinically important PF (ciPF), according to the International Study Group on Pancreatic Fistula criteria.

For the first grouping method, the sensitivity was 36% and 28% and the specificity was 80% and 85% for PF and ciPF, respectively. For the second grouping method, the sensitivity was 36% and 29% and the spesificity was 74% and 81% for PF and ciPF, respectively. The unloculated fluid collections were not related to a significant increase in the risk of POPF (P = 0.694).

Abdominal-US has low sensitivity and high specificity for the early diagnosis of POPF after PD.

• Intra-abdominal fluid
• Pancreatic fistula
• Pancreaticoduodenectomy
• Ultrasonography

• Adipose stem cells
• Gastrointestinal leakage
• Postoperative leakage
• SVF
• Stromal vascular fraction

• Classification
• consensus
• definition
• morbidity
• pancreas fistula
• pancreas surgery
• prediction

• Aged
• Anastomosis, Roux-en-Y/adverse effects
• Gastroenterostomy/adverse effects
• Gastroparesis/etiology
• Humans
• Length of Stay
• Middle Aged
• Odds Ratio
• Pancreatic Fistula/etiology
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/methods
• Randomized Controlled Trials as Topic

• Anastomostic leakage
• debridement
• pancreas
• pancreaticoduodenectomy
• stump ligation

• Amylases/blood
• Biomarkers/blood
• Cohort Studies
• Female
• Humans
• Male
• Middle Aged
• Pancreas/enzymology
• Pancreatic Fistula/epidemiology
• Pancreaticoduodenectomy
• Postoperative Complications/epidemiology
• Postoperative Period
• Predictive Value of Tests
• Prospective Studies
• Risk Factors
• Sensitivity and Specificity
• Stomach/enzymology
• Time Factors

• Pancreatic cancer
• pancreatic anastomosis
• pancreatic fistula
• pancreatic resection
• total pancreatectomy