Background: To minimize the risk of pancreatic fistula development afterpancreaticoduodenectomy, we perform a pancreaticojejunostomy procedure thatis characterized by compression of the pancreatic stump by the seromuscularlayer of the jejunum.Methods: To suture the pancreatic parenchyma to the jejunal seromuscular layer,we use 4-0 non-absorbent thread and double-ended needles. After insertion ofa needle from the posterior surface of the pancreatic parenchyma toward itsanterior surface, the serosa of the small intestine is stitched in the direction of theminor axis of the jejunum to approximate the posterior surface of the pancreas. Astitch is made in the posterior parenchymal surface to anchor the suture thread.Two sutures are placed, one at the head of the main pancreatic duct and the otherat the bottom of the pancreas.During all-layer suturing of the pancreatic duct tothe jejunum, three support threads are placed at the three points of an imaginaryequilateral triangle, and sutures are added as needed, depending on the size ofthe pancreatic duct. Generally, nine sutures are used, fewer when the pancreaticduct is small in diameter. Note that there is a total of four needle tips/threadscoming through the anterior surface of the pancreas. After the all-layer suture ofthe pancreatic duct to the jejunam is tied off, the 4-0 non-absorbent thread thatwas used to stitch the pancreatic parenchyma to the jejunal seromuscular layeris used to stitch the seromuscular layer of the small intestine in the direction ofthe minor axis to approximate the anterior wall of the small intestine.Although itappears as though pressure is being applied when the branch of the pancreaticduct that is exposed to the pancreatic cut end is closed, ligation should be gentle.Study Patients: We conducted a study of 222 patients who underwentpancreaticojejunostomy. The patients comprised three groups treated during threedifferent time periods, and we compared pancreatic fistula rates between thesegroups. The first group was treated between 2005 and 2009, the second groupwas treated between 2010 and 2012, and fast-track perioperative managementwas undertaken in this group, and the third group was treated between 2012 and2014, and anastomosis was achieved in this group by serosal compression of thepancreatic stump.Results: The incidences of grade B/C pancreatic fistula were 27.8% (25/90) in thefirst group, 10.3% (9/87) in the second group, and 2.2% (1/45) in the third group(p<0.001).Conclusion: The risk of serious pancreatic fistula at the pancreatic stump can bemarkedly reduced by creation of a modified Blumgart pressure anastomosis.

Background: It has been considered that allowing patients to return to dailylife earlier after surgery helps recovery of physiological function and reducespostoperative complications and hospital stay. We investigated the usefulnessof Fast-Track management in perioperative care of patients undergoingpancreaticoduodenectomy (PD).Methods: Patients (n = 90) who received conventional perioperative managementfrom 2005 to 2009 were included as the ‘conventional group’ (historical controlgroup),and patients who received perioperative care with Fast-Track management (n= 87) from 2010 to 2013 were included as the ‘fast-track group’. To evaluatethe efficacy of perioperative care with fast-track management,the incidenceof postoperative complications and the length of hospital stay were comparedbetween the two groups (comparative study). For statistical analysis, univariateanalysis was performed using the v2 test or Fisher’s exact test.Results: There was no significant difference between the two groups in sex, meanage, presence/absence of diabetes mellitus, preoperative drainage for jaundice,previous disease, operative procedure, mean duration of operation, or blood loss(p=0.01). The incidence of surgical site infection in the conventional group andfast-track group was 28.9 and 14.0 %, respectively, with a significant differencebetween the two groups (p = 0.019). In addition, the incidence of pancreaticfistula (grade B, C) significantlydiffered between the two groups (27.8 % inthe conventional group, 9.0 % in the fast-track group; p = 0.001). The meanpostoperative hospital stay was 36.3 days in the conventional group and 21.9days in the fast-track group (p=0.001).Conclusions: Perioperative care with fast-track management may reducepostoperative complications and decrease the length of hospital stay in patientsundergoing PD.

Background: To minimize the risk of pancreatic fistula development after pancreaticoduodenectomy, we perform a pancreaticojejunostomy procedure that is characterized by compression of the pancreatic stump by the seromuscular layer of the jejunum. Methods: To suture the pancreatic parenchyma to the jejunal seromuscular layer, we use 4-0 non-absorbent thread and double-ended needles. After insertion of a needle from the posterior surface of the pancreatic parenchyma toward its anterior surface, the serosa of the small intestine is stitched in the direction of the minor axis of the jejunum to approximate the posterior surface of the pancreas. A stitch is made in the posterior parenchymal surface to anchor the suture thread. Two sutures are placed, one at the head of the main pancreatic duct and the other at the bottom of the pancreas.During all-layer suturing of the pancreatic duct to the jejunum, three support threads are placed at the three points of an imaginary equilateral triangle, and sutures are added as needed, depending on the size of the pancreatic duct. Generally, nine sutures are used, fewer when the pancreatic duct is small in diameter. Note that there is a total of four needle tips/threads coming through the anterior surface of the pancreas. After the all-layer suture of the pancreatic duct to the jejunam is tied off, the 4-0 non-absorbent thread that was used to stitch the pancreatic parenchyma to the jejunal seromuscular layer is used to stitch the seromuscular layer of the small intestine in the direction of the minor axis to approximate the anterior wall of the small intestine.Although it appears as though pressure is being applied when the branch of the pancreatic duct that is exposed to the pancreatic cut end is closed, ligation should be gentle. Study Patients: We conducted a study of 222 patients who underwent pancreaticojejunostomy. The patients comprised three groups treated during three different time periods, and we compared pancreatic fistula rates between these groups. The first group was treated between 2005 and 2009, the second group was treated between 2010 and 2012, and fast-track perioperative management was undertaken in this group, and the third group was treated between 2012 and 2014, and anastomosis was achieved in this group by serosal compression of the pancreatic stump. Results: The incidences of grade B/C pancreatic fistula were 27.8% (25/90) in the first group, 10.3% (9/87) in the second group, and 2.2% (1/45) in the third group (p<0.001). Conclusion: The risk of serious pancreatic fistula at the pancreatic stump can be markedly reduced by creation of a modified Blumgart pressure anastomosis.

Background: It has been considered that allowing patients to return to daily life earlier after surgery helps recovery of physiological function and reduces postoperative complications and hospital stay. We investigated the usefulness of Fast-Track management in perioperative care of patients undergoing pancreaticoduodenectomy (PD). Methods: Patients (n = 90) who received conventional perioperative management from 2005 to 2009 were included as the ‘conventional group’ (historical control group), and patients who received perioperative care with Fast-Track management (n = 87) from 2010 to 2013 were included as the ‘fast-track group’. To evaluate the efficacy of perioperative care with fast-track management,the incidence of postoperative complications and the length of hospital stay were compared between the two groups (comparative study). For statistical analysis, univariate analysis was performed using the v2 test or Fisher’s exact test. Results: There was no significant difference between the two groups in sex, mean age, presence/absence of diabetes mellitus, preoperative drainage for jaundice, previous disease, operative procedure, mean duration of operation, or blood loss (p=0.01). The incidence of surgical site infection in the conventional group and fast-track group was 28.9 and 14.0 %, respectively, with a significant difference between the two groups (p = 0.019). In addition, the incidence of pancreatic fistula (grade B, C) significantlydiffered between the two groups (27.8 % in the conventional group, 9.0 % in the fast-track group; p = 0.001). The mean postoperative hospital stay was 36.3 days in the conventional group and 21.9 days in the fast-track group (p=0.001). Conclusions: Perioperative care with fast-track management may reduce postoperative complications and decrease the length of hospital stay in patients undergoing PD.