Background: Pancreaticoduodenectomy (PD) is the traditional treatment forpatients with malignant and benign diseases in the periampullary region. In spiteof advances in surgical techniques and perioperative management, the morbidityrates after PD has been range from 30 to 40 %. Moreover, the mortality afterPD remains 1-5 % even in high-volume centers. A postoperative pancreaticfistula (POPF) is the most common complication after PD, and a POPF from thepancreaticodigestive anastomosis has been the most important cause of morbidity,and also contributes significantly to the prolonged hospitalization and mortalityof patients undergoing PD.Objectives: To review the current surgical and supportive strategies used toprevent the development of POPF, and our procedure and outcome of PD.Systematic review about pancreatico-digestive anastomosis: A systematic reviewincluding meta-analysis and randomized controlled trials (RCTs) regardingpancreatico-digestive anastomosis revealed that PJ and PG did not show anysignificant differences in mortality and morbidity including the risk of POPF,whereas b-PJ significantly decreased the risk of POPF compared with c-PJ.External duct stenting has been described to reduce the risk of clinically relevantPOPF in a metaanalysis and RCTs.Surgical procedures: According these suggestions described above, PD wasperformed in our institution, with D2 dissection of lymph nodes for malignantdiseases. Mesenteric approach was performed to dissection of lymph nodes. Almostall patients underwent subtotal stomachpreserving PD, in which the pylorus andhalf of the antrum were removed. If the tumor invaded the superior mesentericand portal veins (SMV-PV), the involved SMV-PV was resected and reconstructed.A modified Child’s reconstruction was performed with pancreatico-gastrostomy(PG), end-to-side binding pancreatico-jejunostomy (b-PJ) or conventional PJ (c-PJ). External pancreatic duct stent was placed in all patients. Two closed peritonealdrainage tubes were placed posterior to the pancreatico-digestive anastomosis.Results: From September 2009, we performed 126 consecutive PD, including 83male and 43 female with median age of 69 (34-85) years old. Of these patients,104 cases (82.5) had malignant disease such as pancreatic and bile duct cancer,whereas the others had benign disease such as Intraductal papillary mucinousneoplasm (IPMN). SMV-PV resection and reconstruction was performed in 18patients (14%). Two cases of Hepato- pancreatoduodenectomy was includedin this study. Median operative time of the whole patients was 471 (291-869)min, and median operative bleeding was 675 (44-3875) g. PG was performedfrom September 2009 to March 2012 in 59 patients. In this PG group, POPF(Grade B or C) occurred in 15 cases (25%) and overall complication (Clavien-Dindo IIIa or more) occurred in 25 cases (42%). To reduce POPF, the b-PJ wasintroduced at April 2012 and performed in 42 cases until August 2013. In the b-PJgroup, the incidence of POPF was reduced to 9.5% (4 cases), however, overallmorbidity was not significantly improved (36%, 15 cases). Especially, specificsevere complication associated b-PJ, such as repeated bleeding from pancreaticcut and major anastomotic leakage, occurred and re-operation was performed tothese cases. Finally, the c-PJ was introduced at September 2013 and performedin 25 cases until now. The incidence of POPF was gained to 16% (4 cases) andoverall morbidity was not significantly improved (36%, 9 cases), however, severecomplication due to PJ has not occurred. Importantly, we have archived zeromortality in consecutive 126 PD patients.Conclusion: The systematic review suggested that the successful managementof pancreatic anastomoses may depend more on meticulous surgical technique,surgical volume and other management parameters, rather than on the techniqueused. Whereas the morbidity has been still high, we have archived zero mortalityin consecutive 126 PD. Surgical techniques and perioperative managementsshould be improved more in the future.

Background: Pancreaticoduodenectomy (PD) is the traditional treatment for patients with malignant and benign diseases in the periampullary region. In spite of advances in surgical techniques and perioperative management, the morbidity rates after PD has been range from 30 to 40 %. Moreover, the mortality after PD remains 1-5 % even in high-volume centers. A postoperative pancreatic fistula (POPF) is the most common complication after PD, and a POPF from the pancreaticodigestive anastomosis has been the most important cause of morbidity, and also contributes significantly to the prolonged hospitalization and mortality of patients undergoing PD. Objectives: To review the current surgical and supportive strategies used to prevent the development of POPF, and our procedure and outcome of PD. Systematic review about pancreatico-digestive anastomosis: A systematic review including meta-analysis and randomized controlled trials (RCTs) regarding pancreatico-digestive anastomosis revealed that PJ and PG did not show any significant differences in mortality and morbidity including the risk of POPF, whereas b-PJ significantly decreased the risk of POPF compared with c-PJ. External duct stenting has been described to reduce the risk of clinically relevant POPF in a metaanalysis and RCTs. Surgical procedures: According these suggestions described above, PD was performed in our institution, with D2 dissection of lymph nodes for malignant diseases. Mesenteric approach was performed to dissection of lymph nodes. Almost all patients underwent subtotal stomachpreserving PD, in which the pylorus and half of the antrum were removed. If the tumor invaded the superior mesenteric and portal veins (SMV-PV), the involved SMV-PV was resected and reconstructed. A modified Child’s reconstruction was performed with pancreatico-gastrostomy (PG), end-to-side binding pancreatico-jejunostomy (b-PJ) or conventional PJ (c- PJ). External pancreatic duct stent was placed in all patients. Two closed peritoneal drainage tubes were placed posterior to the pancreatico-digestive anastomosis. Results: From September 2009, we performed 126 consecutive PD, including 83 male and 43 female with median age of 69 (34-85) years old. Of these patients, 104 cases (82.5) had malignant disease such as pancreatic and bile duct cancer, whereas the others had benign disease such as Intraductal papillary mucinous neoplasm (IPMN). SMV-PV resection and reconstruction was performed in 18 patients (14%). Two cases of Hepato- pancreatoduodenectomy was included in this study. Median operative time of the whole patients was 471 (291-869) min, and median operative bleeding was 675 (44-3875) g. PG was performed from September 2009 to March 2012 in 59 patients. In this PG group, POPF (Grade B or C) occurred in 15 cases (25%) and overall complication (Clavien- Dindo IIIa or more) occurred in 25 cases (42%). To reduce POPF, the b-PJ was introduced at April 2012 and performed in 42 cases until August 2013. In the b-PJ group, the incidence of POPF was reduced to 9.5% (4 cases), however, overall morbidity was not significantly improved (36%, 15 cases). Especially, specific severe complication associated b-PJ, such as repeated bleeding from pancreatic cut and major anastomotic leakage, occurred and re-operation was performed to these cases. Finally, the c-PJ was introduced at September 2013 and performed in 25 cases until now. The incidence of POPF was gained to 16% (4 cases) and overall morbidity was not significantly improved (36%, 9 cases), however, severe complication due to PJ has not occurred. Importantly, we have archived zero mortality in consecutive 126 PD patients. Conclusion: The systematic review suggested that the successful management of pancreatic anastomoses may depend more on meticulous surgical technique, surgical volume and other management parameters, rather than on the technique used. Whereas the morbidity has been still high, we have archived zero mortality in consecutive 126 PD. Surgical techniques and perioperative managements should be improved more in the future.

Pancreatic cancer is the fifth leading cause of cancer-related death in Japan. Surgical treatment is the effective way to achieve a long survival. Because of the development of surgical procedure and perioperative management, pancreatic surgery becomes safer. However, it still includes a certain number of morbidities and mortalities. It is important to perform safe operation for long survival. We herein introduce our operative procedure for pancreatic surgery including pancreaticoduodenectomy (PD) and distal pancreatectomy. In patients undergoing PD, leakage from the pancreatic anastomosis remains an important cause of morbidity and contributes to prolonged hospitalization and mortality. Recently, a new end-to-end pancreatojejunostomy technique without the use of any stitches through the pancreatic texture or pancreatic duct has been developed. In this novel anastomosis technique, the pancreatic stump is first sunk into deeply and tightened with a purse string in the bowel serosa. We modified this method in an end-to-side manner to complete the insertion of the pancreatic stump into the jejunum, independent of the size of the pancreas or the jejunum. Since April 2013, we have performed this new anastomosis technique in 36 patients. The breakdown of preoperative diagnosis of 36 patients were 13 pancreatic cancers, 8 extrahepatic bile duct cancers, 7 intraductal papillary mucinous neoplasms and so on. Of 36 PD, 32 were subtotal stomach preserving PD (SSPPD), and the rest were SSPPD combined with left hemihepatectomy or distal pancreatectomy, and middle pancreatectomy. The concentration of amylase in discharged fluid through an abdominal drain decreased day by day. According to the ISGPF definition, pancreatic fistula (PF) was observed in 4 patients (11%). Of 4, only 1 case had grade C PF. This case had a hemorrhage from pancreatic cut end. This occurred probably because the pancreatic cut end was not compressed by the intestinal wall with this technique. This case had reoperation and the hemostasis of pancreatic cut end was secured. The other severe complications were not observed. This new method can be performed safely and is expected to reduce the occurrence of leakage from PD. The development of PF following distal pancreatectomy is an unsolved problem. We introduce a simple technique, the parallel suturing technique, which prevents severe PF by hand-sewn closure of the pancreatic stump. After standard distal pancreatectomy in the described cases, the main pancreatic duct was secured. The stump of the pancreatic remnant was closed with three nonabsorbable monofilament sutures. The three sutures were positioned about 3 mm proximal to the cut end of the pancreas and tied parallel to the pancreatic stump. Ascites fluid was collected through a drain tube, and its concentration of amylase was measured on days 1, 2, 3, and 4 postoperatively. PF was diagnosed according to the ISGPF classification. On postoperative day 4, three patients were categorized as having grade A PF, six were diagnosed with no PF, and the drain tubes of the remaining three were removed on day 3. This simple technique may effectively lighten the severity of PF following distal pancreatectomy. It may have a particular advantage in patients with a wide pancreatic stump.