Reduction of pancreatic leak rate after pancreaticoduodenectomy by changing anastomotic and drainage techniques: a long-term single center experience


  • Mohamed M. Elsheikh Department of General Surgery, Faculty of Medicine, Tanta University, Egypt
  • Amir F. Abdelhamid Department of General Surgery, Faculty of Medicine, Tanta University, Egypt
  • Hossam R. Moussa Department of General Surgery, Faculty of Medicine, Tanta University, Egypt



Pancreaticoduodenectomy, Early experience, Late experience, Technical modifications


Background: Pancreaticoduodenectomy is the best curative option for malignant pancreatic head neoplasms with a high perioperative morbidity rate. Pancreatic leak is the most feared complication. This study was done to describe our early and late experience outcomes of PD after implementing technical modifications to decrease the postoperative incidence of pancreatic leak.

Methods: The data of 53 patients were collected and divided into two groups: the early experience group (27 cases) and the late experience group (26 cases). The main two modifications performed in late group were Heidelberg technique for pancreatojejunostomy anastomosis (all cases) and irrigation of the pancreatic anastomosis (selected cases).

Results: All preoperative demographic, clinical, laboratory, and intraoperative findings showed insignificant differences between the two groups (p≥0.05). Nonetheless, cases in the late group had shorter operative time, less intraoperative blood loss, and less need for blood transfusion (p<0.05(. Postoperatively, the incidence of pancreatic leak decreased with technical modifications (11.54% vs. 37.04% in the early group). The late group showed earlier time to oral intake and shorter hospitalization periods. In-hospital mortality occurred in 14.81% of early cases secondary to pancreatic leak and subsequent secondary haemorrhage and multiorgan failure. Obesity (p<0.001), soft pancreas (p<0.001), and small pancreatic duct diameter (p=0.007) were significant predictors of pancreatic leak.

Conclusions: Surgical expertise and technical modifications play a crucial role in improving PD outcomes with less incidence of complications, earlier oral intake, and shorter hospitalization period.


Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226(3):248-57.

Skórzewska M, Kurzawa P, Ciszewski T, Pelc Z, Polkowski WP. Controversies in the diagnosis and treatment of periampullary tumours. Surg Oncol. 2022;44:101.

Baum C, Soliman AS, Brown HE, Seifeldin IA, Ramadan M, Lott B, et al. Regional Variation of Pancreatic Cancer Incidence in the Nile Delta Region of Egypt over a Twelve-Year Period. J Cancer Epidemiol. 2020;2020:603.

[Grochola LF, Seeger N, Stättner S, Søreide K, Breitenstein S. Standard Pancreatoduodenectomy for Resectable Pancreatic Cancer. In: Søreide K, Stättner S, eds. Textbook of Pancreatic Cancer: Principles and Practice of Surgical Oncology. USA: Springer International Publishing; 2021:829-45.

Peng JS, Morris-Stiff G. Overview of Resections for Pancreatic and Periampullary Cancer. In: Surgery for Pancreatic and Periampullary Cancer: Principles and Practice. Singapore: Springer Singapore; 2018:11-21.

El Nakeeb A, Askar W, Atef E, Hanafy EE, Sultan AM, Salah T, et al. Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases. World J Gastroenterol. 2017;23(38):7025-36.

Adamenko O, Ferrari C, Porreca A, Seewald S, Groth S, Gutzwiller JP, Schmidt J, et al. Perianastomotic Irrigation With Passive Drainage Dramatically Decreases POPF Rate After High-risk Pancreatico-duodenectomy. Ann Surg Open. 2022;3(2):e154.

Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol. 2016;22(34):7797-805.

Andrianello S, Pea A, Pulvirenti A, Allegrini V, Marchegiani G, Malleo G, et al. Pancreatico-jejunostomy after pancreaticoduodenectomy: Suture material and incidence of post-operative pancreatic fistula. Pancreatology. 2016;16(1):138-41.

Muscari F, Suc B, Kirzin S, Hay JM, Fourtanier G, Fingerhut A, et al. Risk factors for mortality and intra-abdominal complications after pancreatoduo-denectomy: multivariate analysis in 300 patients. Surgery. 2006;139(5):591-8.

Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, et al. Pancreatic anastomosis after pancreatoduodenectomy: a position statement by the International Study Group of Pancreatic Surgery. Surgery. 2017;161(5):1221-34.

Torres OJM, Costa R, Costa FFM, Neiva RF, Suleiman TS, Souza Y, et al. Modified heidelberg technique for pancreatic anastomosis. Arq Bras Cir Dig. 2017;30(4):260-3.

Bootsma BT, Plat VD, van de Brug T, Huisman DE, Botti M, van den Boezem PB, et al. Somatostatin analogues for the prevention of pancreatic fistula after open pancreatoduodenectomy: A nationwide analysis. Pancreatology. 2022;22(3):421-6.

Song KB, Kim SC, Lee W, Hwang DW, Lee JH, Kwon J, et al. Laparoscopic pancreaticoduo-denectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc. 2020;34(3):1343-52.

Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584-91.

Sonbare D. Bile leakage after hepatobiliary and pancreatic surgery: is the ISGLS definition too simple? Surgery. 2012;151(4):634.

Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149(5):680-8.

Mao SH, Shyr BS, Chen SC, Wang SE, Shyr YM, Shyr BU. Risk factors for delayed gastric emptying in pancreaticoduodenectomy. Sci Rep. 2022;12(1): 22270.

Tsamalaidze L, Stauffer JA. Pancreaticoduo-denectomy: minimizing the learning curve. J Vis Surg. 2018;4:64.

Chowdappa R, Tiwari AR, Ranganath N, Kumar RV. Modified Heidelberg technique of pancreatic anastomosis postpancreaticoduodenectomy - 10 years of experience. South Asian J Cancer. 2019;8(2):88-91.

Pergolini I, Scheufele F, Demir E, Schorn S, Friess H, Ceyhan GO, et al. Continuous irrigation after pancreatectomy: a systematic review. Langenbecks Arch Surg. 2023;408(1):348.

Giuliano K, Ejaz A, He J. Technical aspects of pancreaticoduodenectomy and their outcomes. Chin Clin Oncol. 2017;6(6):64.

Wilson JA, Clark JJ. Obesity: impediment to wound healing. Crit Care Nurs Q. 2003;26(2):119-32.

Pierpont YN, Dinh TP, Salas RE, Johnson EL, Wright TG, Robson MC, et al. Obesity and surgical wound healing: a current review. ISRN Obes. 2014;2014: 638.

Rohm TV, Meier DT, Olefsky JM, Donath MY. Inflammation in obesity, diabetes, and related disorders. Immunity. 2022;55(1):31-55.

Hwang HK, Park JS, Park CI, Kim JK, Yoon DS. The impact of body mass index on pancreatic fistula after pancreaticoduodenectomy in Asian patients on the basis of Asia-Pacific perspective of body mass index. JOP. 2011;12(6):586-92.

Shimoda M, Katoh M, Yukihiro I, Kita J, Sawada T, Kubota K. Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy. Am Surg. 2012;78(2):190-4.

Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, et al. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB. 2018;20(11):992-1003.

McMillan MT, Vollmer CM, Jr. Predictive factors for pancreatic fistula following pancreatectomy. Langenbecks Arch Surg. 2014;399(7):811-24.

Ke Z, Cui J, Hu N, Yang Z, Chen H, Hu J, et al. Risk factors for postoperative pancreatic fistula: Analysis of 170 consecutive cases of pancreaticoduodenectomy based on the updated ISGPS classification and grading system. Medicine. 2018;97(35):e12151.

Hassan RA, Zidan A, Jabir MA, Abdelshafy M, Abdallah M, Taha AMI. Risk factors predicting the development of a pancreatic fistula following pancreaticoduodenectomy: A retrospective cohort study. IJS. 2022;45:1005.

Jin J, Xiong G, Li J, Guo X, Wang M, Li Z, et al. Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy. Ann Transl Med. 2021;9(1):41.

Chen JS, Liu G, Li TR, Chen JY, Xu QM, Guo YZ, et al. Pancreatic fistula after pancreaticoduodenectomy: Risk factors and preventive strategies. J Cancer Res Ther. 2019;15(4):857-63.

Purkayastha J, Bannoth S, Talukdar A, Borthakur BB, Kalita D, Das G, et al. Postoperative pancreatic fistulas after pancreaticoduodenectomy for malignancy: A Northeast Indian tertiary cancer center study. JGH. 2021;5(9):1009-14.

Samayoa AX, Vu T. The utility of irrigation drainage following video-assisted pancreatic necrosectomy. Ann R Coll Surg Engl. 2019;101:73-4.






Original Research Articles