Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy

Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy Atsushi Tomioka, Nao Kawaguchi, Yasuhiko Ueda, Shuhei Kushiyama, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8105675/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 41 You are reading this latest preprint version Abstract Background: Postoperative pancreatic fistula (POPF) is a major complication followingpancreaticoduodenectomy (PD) and is often associated with delayed recovery and postoperative hemorrhage (PPH). The falciform ligament interposition technique (FIT) employs the falciform ligament as a vascularized flap positioned between the pancreaticojejunostomy (PJ) and the hepatic artery. This approach provides a mechanical barrier and enables functional separation of the drainage spaces, potentially reducing the risk of POPF-related PPH. Methods: This retrospective study included all consecutive patients who underwent PD at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan) between January 2018 and June 2024. Postoperative outcomes, including drain-related variables, incidence of POPF, and occurrence of PPH, were systematically analyzed. Results: Among 229 patients who underwent PD with the FIT, the median amylase concentration on postoperative day (POD) 3 was significantly lower in the hepaticojejunostomy (HJ) drain compared with the PJ drain (74 vs. 255 IU/L, p < 0.001). In the subgroup of 102 patients who developed POPF; Grades biochemical leak [BL], B, or C), the median POD 3 amylase concentration in the HJ drain remained significantly lower than that in the PJ drain (233 vs. 1,619 IU/L, p < 0.001), confirming effective compartmentalization of the drainage spaces. Among patients with Grade B POPF, 24 (49.0%) required additional percutaneous drainage, which was safely and easily performed via the anterior abdominal wall because the fluid collection was confined to the PJ site immediately beneath it. Postpancreatectomy hemorrhage (PPH) originating from the gastroduodenal artery (GDA) stump occurred in two patients (0.9%). Conclusions: This compartmentalization strategy yielded three major clinical advantages: 1. Early drain removal and simplified single-drain care 2. Localized control and safer interventionl —allowing efficient infection control, and 3. Structural protection of major arteries —reducing arterial exposure to pancreatic enzymes and thereby minimizing the risk of PPH from the GDA stump. The consistently marked amylase gradient observed between the PJ and HJ drains provides quantitative evidence that FIT promotes effective physiological separation, ensuring predictable drainage behavior and a safer postoperative environment. Collectively, these findings support FIT as a practical, physiologically sound, and structurally rational approach for postoperative management following PD. Falciform ligament Pancreaticoduodenectomy Postoperative pancreatic fistula Interposition flap Drainage management Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Pancreaticoduodenectomy (PD) is one of the most complex abdominal surgeries, involving the resection and reconstruction of multiple organs and major vessels. Despite advances in surgical techniques and perioperative management, postoperative complications remain common. Among these, postoperative pancreatic fistula (POPF) represents a leading cause of morbidity and mortality [ 1 – 3 ] .When leakage of pancreatic juice is inadequately localized or poorly controlled, it can delay healing and precipitate serious complications, including infection and erosive hemorrhage from adjacent arteries or arterial stumps—collectively known as postpancreatectomy hemorrhage (PPH). In severe cases, PPH can be life-threatening. Furthermore, Grade C POPF has been linked not only to poor short-term outcomes but also to unfavorable long-term prognosis [ 4 ] . To protect vascular structures from exposure to leaked pancreatic enzymes, several surgical strategies have been developed. These include wrapping the vessel stump with the omentum or falciform ligament [ 5 – 8 ] and interposing the falciform ligament between the pancreatic anastomosis and hepatic arterial system [ 9 , 10 ] . However, most previously reported methods have focused primarily on shielding the gastroduodenal artery (GDA) stump, without addressing the broader concept of functional compartmentalization. At our institution, we have refined and standardized this technique—using the falciform ligament as an interposed, vascularized flap—to establish what we term the Falciform Interposition Technique (FIT). This method was designed not only to protect arterial structures but also to achieve intentional and functional separation of the drainage spaces. The present study aimed to assess the clinical feasibility and outcomes of FIT in a large consecutive cohort. We hypothesized that this structural approach would facilitate localized control of pancreatic leakage, simplify postoperative drain management, and reduce the incidence of hemorrhagic complications following PD. Methods Patient Selection All consecutive patients who underwent PD at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan), between January 2018 and June 2024 were eligible for inclusion. Clinical data were obtained from institutional medical records and retrospectively reviewed. At our institution, PD is indicated for periampullary neoplasms—including pancreatic, bile duct, ampullary, and duodenal cancers—as well as selected benign or borderline lesions. Patients were excluded if they met any of the following criteria: Presence of a portal annular pancreas; Two-stage pancreaticojejunostomy (PJ) with complete external drainage; Inadequate falciform ligament volume precluding performance of the FIT; or Undergoing robotic PD, in which FIT was not applied because of technical limitations in the robotic setting. Surgical Procedure All patients underwent open or laparoscopy-assisted subtotal stomach-preserving PD with and without concomitant resection of the regional lymph nodes. The reconstruction procedure comprised a retro-colic jejunal loop with a PJ and hepaticojejunostomy (HJ). PJ included end-to-side duct-to-mucosa anastomosis with the modified Blumgart anastomosis technique [ 11 ] . An internal stent was used when the main pancreatic duct (MPD) diameter was ≤ 4 mm. Gastrojejunostomy was performed using ante-colic Billroth II anastomosis without Braun anastomosis (modified Child’s reconstruction). In laparoscopy-assisted cases, digestive reconstruction was performed through a small laparotomy incision. FIT(Falciform ligament interposition technique) The round ligament was divided near the umbilicus and carefully dissected along the posterior surface of the rectus sheath toward the undersurface of the diaphragm (Fig. 1 a). The surrounding preperitoneal fat was preserved as much as possible to maintain vascularity. The falciform ligament was then divided near the Glisson’s sheath at the hepatic hilum, producing a vascularized, pennant-shaped flap (Fig. 1 b). After completion of the reconstructive phase, the harvested falciform ligament was positioned between the PJ and the hepatic artery to create a physical barrier and achieve spatial separation of these structures (Figs. 1 c and 2 ). For descriptive clarity, the space superior to the interposed falciform ligament—surrounding the PJ—was designated as “Area PJ,” whereas the space inferior to the ligament—around the hepatic artery—was designated as “Area HJ.” Two closed-suction drains were placed intraoperatively: the Area PJ drain was positioned dorsal to the PJ, and the Area HJ drain was placed dorsal to the HJ (Fig. 1 d). Postoperative Drain Management As part of standardized postoperative care, the amylase concentration in the drainage fluid from each site was measured on postoperative day (POD) 3. Drains were removed when the amylase level in the effluent was < 400 IU/L. If the concentration exceeded 400 IU/L, the drain was retained until the fistula resolved or drainage volume markedly decreased. When intra-abdominal fluid collections suggestive of infection were detected, additional percutaneous drainage was performed to ensure adequate evacuation. Definition of Morbidity and Mortality POPF was defined according to the 2016 criteria of the International Study Group on Pancreatic Fistula (ISGPF) [ 12 ] . Grade B and C POPFs were classified as clinically relevant. PPH was defined based on the criteria of the International Study Group of Pancreatic Surgery (ISGPS) [ 13 ] . According to these criteria, late extraluminal mild hemorrhage is categorized as Grade B because it may serve as a sentinel event indicating potential for severe bleeding. In this study, Grades B and C hemorrhages were considered PPH. Postoperative mortality was defined as death occurring within 90 days after surgery or during the index hospitalization. Analysis All patients underwent preoperative and postoperative evaluations, including clinical history, physical examination, serum laboratory testing, and pancreatic protocol computed tomography (CT). Amylase concentrations in the drainage fluid were compared between Area PJ and Area HJ in patients who developed POPF. The duration of drain placement was also compared between the two drain sites. Postoperative outcomes, including morbidity, mortality, length of hospital stay, duration of drain placement, and insertion sites of additional drains in patients with Grade B POPF, were systematically analyzed. Statistical Analyses All statistical analyses were performed using JMP Pro, version 17.0.0 (SAS Institute Inc., Cary, NC, USA). Continuous variables were expressed as medians with interquartile ranges, and categorical variables as frequencies and percentages. Paired t -tests were used to compare paired continuous measurements. A two-sided p -value of < 0.05 was considered statistically significant. Ethics Informed consent was obtained in the form of opt-out on the website. All of the patients provided informed consent for the use of their data in our research. The study protocol was approved by the Institutional Review Board of Osaka Medical and Pharmaceutical University (approval number: 2023 − 217, March 18, 2023). Moreover, the study was conducted following the guidelines stipulated in the Declaration of Helsinki. Results A total of 238 patients underwent PD at our institution between January 2018 and June 2024. Of these, nine patients were excluded from the analysis according to the study criteria (Fig. 3 ): two with portal annular pancreas, one who underwent two-stage pancreatojejunostomy with complete external drainage, four in whom the falciform ligament volume was insufficient for the FIT, and two who underwent robotic PD, in which the technique could not be applied. Patient Characteristics and Operative Details The median patient age was 72 years (interquartile range [IQR], 66–77 years); 130 were men and 99 were women. The median body mass index (BMI) was 22.1 kg/m² (IQR, 19.8–24.4) (Table 1 ). Table 1 Patients’ characteristics Characteristics and Factors Entire Cohort (n = 229) Patient Characteristics Age, years, median (IQR) 72[66–77] Sex (Male/Female), n (%) 130(57) BMI, kg/m², median (IQR) 22.1[19.8–24.4] Histopathological Findings, n (%) Pancreatic ducal adenocarcinoma 80 (34.9) Resectable 49 Borderline resectable 30 Locally advanced 1 Cholangiocarcinoma 50 (21.8) Ampullary carcinoma 30 (13.1) Duodenal carcinoma 10 (4.4) Metastatic pancreatic tumor 2(0.87) IPMC (invasive carcinoma) 15 (6.6) IPMN (LGD, HGD) 25 (10.9) NEN 10 (4.4) Benign tumor 1 (0.44) Others 6 (2.6) Surgical Factor Operative time, min, median (IQR) 440 [387–501] Blood loss, g, median (IQR) 370 [220–580] Type of Surgery, n (%) Open 177 (77.3) Laparoscopic 52 (22.7) Robotic 0 Surgical Findings Diameter of MPD, mm, median (IQR) 4[3–5] Pancreatic texture (soft/hard), n (%) 139/90 (61/39) BMI, body mass index; HGD, high-grade dysplasia; IPMC, intraductal papillary mucinous carcinoma; IPMN, intraductal papillary mucinous neoplasm; IQR, interquartile range; LGD, low-grade dysplasia; MPD, main pancreatic duct; NEN, neuroendocrine neoplasm. Histopathological examination revealed malignant tumors in 187 patients (81.7%). Among patients with pancreatic cancer, 49 (59.8%) had resectable, 30 (36.6%) had borderline resectable, and one (1.2%) had locally advanced cancer, as defined by the International Association of Pancreatology classification of anatomical resectability [ 14 ] . Operative Procedures and Findings Laparoscopy-assisted PD was performed in 52 patients (22.7%). The median operative time was 440 minutes (IQR, 387–501 minutes), and the median intraoperative blood loss was 370 mL (IQR, 220–580 mL). The median MPD diameter was 4 mm (IQR, 3–5 mm). Pancreatic texture was soft in 139 patients (61%) and hard in 90 patients (39%) (Table 1 ). Drain Amylase Concentrations, Drain Management, and POPF On POD 3, the median amylase concentration in the entire cohort was 255 IU/L (interquartile range [IQR], 14–1621 IU/L) in the Area PJ drain and 74 IU/L (IQR, 9–247 IU/L) in the Area HJ drain, showing a significant difference ( p < 0.001). These data, although not included in figures or tables, are provided here for completeness. Among patients who developed POPF Grades biochemical leak [BL], B, or C; n = 102), the median POD3 amylase concentration was also significantly lower in the Area HJ drains than in the Area PJ drains—233 IU/L (IQR, 74–907 IU/L) versus 1619 IU/L (IQR, 660–4255 IU/L), respectively ( p < 0.001) (Fig. 4 a). When the amylase concentration in the Area HJ drain was low, it was removed earlier than the Area PJ drain, enabling simplified postoperative management with a single drain. In the Grade BL and B POPF cohorts, the median durations of drain placement were 23 days for the Area PJ drain and 7 days for the Area HJ drain (Fig. 4 b). Among patients with Grade B POPF, 24 (49.0%) required additional percutaneous drainage. In all such cases, additional drains were safely and easily inserted through the anterior abdominal wall, as the fluid collection was localized around the PJ site (Table 2 ). Table 2 Morbidities and Outcomes orbidities and Outcomes Entire cohort (n = 229) POPF, n (%) Grade BL 53 (23.1) Grade B 49 (21.4) Additional drain 24 (10.4) Drainage route(anterior abdomen/others) 24/0 Persisting drainage > 3 weeks 21(9.2) Angiographic procedures 4(1.7) Grade C 2 (0.9) Reoperation 1 (0.3) Organ failure 1(0.3) PPH, n (%) 8(3.5) PSA (GDA stump) 2 (0.9) GDA stump without PSA 1(0.4) Transverse pancreatic artery 2 (0.9) Jejunal artery 1 (0.4) Sentinel bleeding (unknown origin) 2 (0.9) Postoperative Hospital Stay, day, median (IQR) Entire cohort 23 [14–33] Grade BL POPF cohort (n = 53) 24[18–31] Grade B POPF cohort (n = 49) 35[29–43] No POPF cohort (n = 125) 15[12–23] BL, biochemical leak; GDA, gastroduodenal artery; IQR, interquartile range; POPF, postoperative pancreatic fistula (POPF); PPH, postpancreatectomy hemorrhage; PSA, pseudoaneurysm. The median postoperative hospital stay was 23 days in the overall cohort, 24 days in the Grade BL POPF cohort, 35 days in the Grade B POPF cohort, and 15 days in patients without POPF. The incidences of Grade B and C POPF were 21.4% (49 cases) and 0.9% (2 cases), respectively. A total of eight patients (3.5%) developed PPH (Tables 2 and 3 ). Major bleeding occurred in six cases (Cases 1–6). Among these, two cases (0.9%) (Cases 1 and 2) were due to pseudoaneurysm rupture at the GDA stump following POPF, diagnosed by contrast-enhanced CT or angiography. Two cases (Cases 3 and 4) involved bleeding from a transverse pancreatic artery, with Case 4 presenting within 24 hours postoperatively, suggesting no relation to POPF. Two additional cases (Cases 5 and 6) were attributed to intraoperative hemostatic failure—one (Case 5) associated with locally advanced pancreatic cancer invading the GDA root, and the other (Case 6) with jejunal arterial injury. Case 5 experienced fatal GDA stump hemorrhage on POD 21. Neither of these hemostasis-related cases developed POPF. The remaining two patients (Cases 7 and 8) exhibited minor sentinel bleeding that did not progress to major hemorrhage. Table 3 Summary of cases with PPH Case No Type Of Hemorrhage Timing of Bleeding Drain Amylase (IU/L) Drain Amylase (IU/L) Drain Amylase (IU/L) Drain Amylase (IU/L) Procedure Mortality (POD) PJ, POD3 HJ, POD3 PJ, POD7 HJ, POD7 1 PSA (GDA’s stump) 17 1439 690 1261 187 IVR, reoperation no 2 PSA (GDA’s stump) 11 5076 171 131600 161 IVR no 3 Transverse pancreatic artery 9 129 119 N/A(already removed) N/A(already removed) IVR no 4 Transverse pancreatic artery 1 7151 973 N/A N/A IVR no 5 Inappropriate hemostat (GDA) 21 335 170 17 5 IVR yes 6 Inappropriate hemostat (Jejunal artery) 4 767 30 211 9 IVR no 7 Sentinel bleeding (unknown origin) 10 287 135 26 N/A(already removed) IVR no 8 Sentinel bleeding (unknown origin) 6 234300 1756 91388 44 IVR no GDA, gastroduodenal artery; HJ, hepaticojejunostomy; IVR, interventional radiology; N/A, not applicable; PJ, pancreaticojejunostomy; POD, postoperative day; PPH, postpancreatectomy hemorrhage; PSA, pseudoaneurysm. Discussion POPF remains a major complication after PD and can lead to life-threatening PPH. To enhance postoperative drainage management and minimize the risk of PPH, our institution adopted the FIT , which uses the falciform ligament as an interposed flap to establish both physical and functional separation between the PJ and the hepatic artery systems. In this single-institution retrospective study of 229 consecutive patients who underwent PD with FIT, we evaluated postoperative outcomes, including drain-related parameters, POPF, and PPH. The median amylase concentration on POD 3 was significantly lower in the Area HJ drains than in the Area PJ drains ( p = 0.009), confirming effective functional compartmentalization. Among patients with Grade BL and Grade B POPF, the drain placement period was also markedly shorter in the Area HJ drains (7 days) than in the Area PJ drains (23 days) ( p < 0.001). In Grade B POPF, additional percutaneous drainage could be safely performed via the anterior abdominal wall, as FIT effectively localized the fluid collection to a superficial layer. Clinically relevant POPF (Grades B and C) and PPH occurred in 22.3% and 3.5% of patients, respectively. PPH due to pseudoaneurysm formation at the GDA stump was observed in two cases (0.9%) . Collectively, these findings indicate that FIT offers an effective and feasible approach to postoperative drainage control while maintaining structural and functional separation between the hepatic artery and PJ. This separation confers three principal clinical benefits: Early drain removal and simplified single-drain care: A pronounced amylase gradient allows early removal of the Area HJ drain, enabling streamlined management with a single Area PJ drain (Fig. 4). This approach simplifies postoperative care, enhances patient comfort, facilitates early mobilization, and promotes infection control and fistula maturation. Localized control and safer intervention: By confining pancreatic leakage to the Area PJ, FIT enables straightforward and safe percutaneous drainage through the anterior abdominal wall, minimizing the risk of injury to adjacent organs. Complete clearance of infected fluid was achieved in all cases requiring intervention (Fig. 5). As reported previously, bacterial infection is a key factor in the development of Grade B and C POPFs [15–18] ; thus, effective localized drainage remains essential for infection control. Structural protection of major arteries: FIT serves as a mechanical barrier that prevents arterial erosion, particularly of the hepatic artery system and GDA stump, thereby reducing the risk of delayed hemorrhage. Previous studies have reported a PPH incidence of 2%–10% following PD [19–22] . In the present series, PPH occurred in 3.5% of patients, with only two cases (0.9%) attributable to pseudoaneurysm rupture at the GDA stump following POPF—the precise event that FIT is designed to prevent. Although several earlier reports described wrapping vessel stumps with omentum or the falciform ligament to protect the GDA stump [9,10] , those methods focused solely on hemostatic reinforcement. In contrast, the core innovation of FIT lies in its deliberate creation of a two-compartment drainage system , combining vessel protection with controlled compartmentalization. It is acknowledged that amylase concentrations in drains placed anatomically distant from the PJ—such as those near the HJ—may occasionally be lower even without an interposed barrier. However, this natural separation is often inconsistent and limited in effect. The FIT converts this passive anatomical relationship into an intentional and reproducible compartmentalization strategy , ensuring consistent physiological separation. The large and consistent amylase gradient observed in our study provides quantitative evidence that FIT reinforces this separation, resulting in predictable drainage behavior and a safer postoperative environment. Taken together, our findings underscore both the conceptual and practical significance of FIT. It is not merely a technical refinement but a rational, physiology-based framework for safer and more efficient postoperative management after PD. This study has several limitations. It was a retrospective, single-arm cohort analysis without a control group of patients who underwent PD without FIT. Therefore, definitive conclusions regarding comparative efficacy cannot be drawn. Nevertheless, the large, consecutive cohort provides substantial evidence supporting the procedural safety and mechanistic validity of FIT. Although the observed amylase gradient demonstrates functional separation, confirming its effect on hemorrhagic outcomes and long-term prognosis will require prospective, multicenter comparative studies. Future research comparing FIT with conventional drainage techniques is warranted to validate its clinical value and optimize postoperative strategies after PD. Conclusions The FIT is an effective and reproducible approach that establishes a robust structural barrier between the PJ and the hepatic arterial system, including the GDA stump. The pronounced amylase gradient observed between the two drainage areas quantitatively demonstrates the functional separation achieved by the interposed falciform ligament. This configuration facilitates early and rational drain removal, streamlines postoperative management of pancreatic fistula through single-drain control and localized infection management, and may reduce the risk of hemorrhagic complications, including pseudoaneurysm formation at the GDA stump. Overall, these findings support FIT as a practical, physiologically grounded, and structurally rational strategy for safer and more efficient postoperative management following PD. Abbreviations If abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided. PD Pancreaticoduodenectomy POPF Postoperative pancreatic fistula PPH Postpancreatectomy hemorrhage FIT Falciform Interposition Technique PJ Pancreaticojejunostomy HJ Hepaticojejunostomy GDA Gastroduodenal artery POD Postoperative day BL Biochemical leak PSA Pseudoaneurysm RPD Robotic Pancreaticoduodenectomy MPD Main pancreatic duct CT Computed tomography Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Institutional Review Board of Osaka Medical and Pharmaceutical University (approval No. 2023-217; March 18, 2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Informed consent for publication was obtained through an opt-out procedure posted on the institutional website. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding, grants, or other financial support was received for this study. Authors ’ contributions Atsushi Tomioka: Writing—original draft. Nao Kawaguchi: Conceptualization. Yasuhiko Ueda: Investigation. Shuhei Kushiyama: Data curation. Koji Komeda: Methodology. Mitsuhiro Asakuma: Writing—review and editing. Hideki Tomiyama: Visualization. Yoshiharu Miyamoto: Supervision. Sang-Woong Lee: Supervision. Acknowledgements The authors thank Enago (www.enago.jp) for providing English language editing assistance. Authors ’ information Atsushi Tomioka, MD, PhD, is an Associate Professor in the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, specializing in pancreatic and biliary surgery. All authors are staff surgeons in the same department with clinical expertise in hepatobiliary-pancreatic surgery. They are members of the Japanese Society of Hepato-Biliary-Pancreatic Surgery and/or the Japan Surgical Society. References Aoki S, Miyata H, Konno H, Gotoh M, Motoi F, Kumamaru H, et al. Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan. J Hepatobil Pancreat Sci. 2017;24:243–51. 10.1002/jhbp.438 . Simon R. Complications after pancreaticoduodenectomy. Surg Clin North Am. 2021;101:865–74. 10.1016/j.suc.2021.06.011 . Mirrielees JA, Weber SM, Abbott DE, Greenberg CC, Minter RM, Scarborough JE. Pancreatic fistula and delayed gastric emptying are the highest-impact complications after whipple. J Surg Res. 2020;250:80–7. 10.1016/j.jss.2019.12.041 . Kawai M, Murakami Y, Motoi F, Sho M, Satoi S, Matsumoto I, et al. Grade B pancreatic fistulas do not affect survival after pancreatectomy for pancreatic cancer: a multicenter observational study. Surgery. 2016;160:293–305. 10.1016/j.surg.2016.02.032 . Ramia JM, de la Plaza R, Adel F, Ramiro C, Arteaga V, Garcia-Parreño J. Wrapping in pancreatic surgery: a systematic review. ANZ J Surg. 2014;84:921–4. 10.1111/ans.12491 . Werey F, Browet F, Mauvais F. Falciform ligament wrap during laparoscopic pancreatoduodenectomy. J Visc Surg. 2019;156:50–4. 10.1016/j.jviscsurg.2018.11.004 . Andreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, et al. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB. 2020;22:1227–39. 10.1016/j.hpb.2020.05.003 . Marique L, Codjia T, Sauvanet A. Retromesenteric omental flap for complete arterial coverage during pancreaticoduodenectomy: surgical technique. World J Surg. 2022;46:2440–3. 10.1007/s00268-022-06641-7 . Okada K, Murakami Y, Uemura K, Kondo N, Nakagawa N, Seo S, et al. Flooring the major vessels with falciform ligament to prevent post-pancreatectomy hemorrhage. World J Surg. 2020;44:3478–85. 10.1007/s00268-020-05637-5 . Abe N, Sugiyama M, Suzuki Y, Yanagida O, Masaki T, Mori T, et al. Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels. J Hepatobiliary Pancreat Surg. 2009;16:184–8. 10.1007/s00534-008-0036-8 . Fujii T, Sugimoto H, Yamada S, Kanda M, Suenaga M, Takami H, et al. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical Control Study J. J Gastrointest Surg. 2014;18:1108–15. 10.1007/s11605-014-2523-3 . 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. 2019;161:584–91. 10.1016/j.surg.2016.11.014 . Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH)-an international study group of pancreatic surgery (ISGPS) definition. Surgery. 2007;142:20–5. 10.1016/j.surg.2007.02.001 . Isaji S, Mizuno S, Windsor JA, Bassi C, Fernández-Del Castillo C, Hackert T, et al. International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017. Pancreatology. 2018;18:2–11. 10.1016/j.pan.2017.11.011 . Chiba N, Ochiai S, Yokozuka K, Gunji T, Sano T, Tomita K, et al. Risk factors for life-threatening grade c postoperative pancreatic fistula after pancreatoduodenectomy compared to grade B. Anticancer Res. 2019;39:2199–205. 10.21873/anticanres.13335 . Li GQ, Zhang T, Yang WG, Zhong HL, Xiao P, Liu LW, et al. Gut microbiota patterns associated with somatostatin in patients undergoing pancreaticoduodenectomy: a prospective study. Cell Death Discov. 2020;6:94. 10.1038/s41420-020-00329-4 . Langheinrich M, Wirtz S, Kneis B, Gittler MM, Tyc O, Schierwagen R, et al. Microbiome patterns in matched bile, duodenal, pancreatic tumor tissue, drainage, and stool samples: association with preoperative stenting and postoperative pancreatic fistula development. J Clin Med. 2020;9:2785. 10.3390/jcm9092785 . Xiang C, Chen Y, Liu X, Zheng Z, Zhang H, Tan C. Prevention and treatment of grade c postoperative pancreatic fistula. J Clin Med. 2022;11:7516. 10.3390/jcm11247516 . 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;226:248–57. 10.1097/00000658-199709000-00004 . Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg. 1998;227:236–41. 10.1097/00000658-199802000-00013 . Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg. 2004;199:186–91. 10.1016/j.jamcollsurg.2004.04.005 . Khuri S, Mansour S, Obeid A, Azzam A, Borzellino G, Kluger Y. Postpancreatoduodenectomy hemorrhage: association between the causes and the severity of the bleeding. Visc Med. 2021;37:171–9. 10.1159/000509894 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 29 Dec, 2025 Reviews received at journal 26 Dec, 2025 Reviews received at journal 24 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 11 Dec, 2025 Reviews received at journal 09 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviews received at journal 06 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers invited by journal 02 Dec, 2025 Editor invited by journal 20 Nov, 2025 Editor assigned by journal 18 Nov, 2025 Submission checks completed at journal 18 Nov, 2025 First submitted to journal 13 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8105675","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555462007,"identity":"5a0a4449-0045-4949-8c58-a0e9e733fb4d","order_by":0,"name":"Atsushi Tomioka","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Atsushi","middleName":"","lastName":"Tomioka","suffix":""},{"id":555462008,"identity":"11a8ef8b-37c3-4ef6-8db4-ed60db98ca50","order_by":1,"name":"Nao Kawaguchi","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Nao","middleName":"","lastName":"Kawaguchi","suffix":""},{"id":555462009,"identity":"da80a13b-d14e-4d94-ba25-9720fe68e3e2","order_by":2,"name":"Yasuhiko Ueda","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Yasuhiko","middleName":"","lastName":"Ueda","suffix":""},{"id":555462010,"identity":"c91c890a-7abd-4c90-ba83-d6ee25782020","order_by":3,"name":"Shuhei Kushiyama","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Shuhei","middleName":"","lastName":"Kushiyama","suffix":""},{"id":555462011,"identity":"0f5ec7e9-1640-4fce-a12e-d2a1bcffcb35","order_by":4,"name":"Koji Komeda","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Komeda","suffix":""},{"id":555462013,"identity":"67c6384a-a532-431e-a4c5-f2eba7fc09f2","order_by":5,"name":"Mitsuhiro Asakuma","email":"data:image/png;base64,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","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":true,"prefix":"","firstName":"Mitsuhiro","middleName":"","lastName":"Asakuma","suffix":""},{"id":555462015,"identity":"d10f3b0e-0426-421c-86aa-12049520bf2f","order_by":6,"name":"Hideki Tomiyama","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Hideki","middleName":"","lastName":"Tomiyama","suffix":""},{"id":555462016,"identity":"4c0d611b-da4a-4266-b530-42520a023c99","order_by":7,"name":"Yoshiharu Miyamoto","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Yoshiharu","middleName":"","lastName":"Miyamoto","suffix":""},{"id":555462017,"identity":"21ab7102-c89c-44f4-a2ec-b1b9b6ae76f5","order_by":8,"name":"Sang-Woong Lee","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Sang-Woong","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2025-11-13 12:23:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8105675/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8105675/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-026-03661-1","type":"published","date":"2026-03-13T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97654767,"identity":"c5510e8f-6213-48c9-b19d-c9ddfdf74bd4","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2483773,"visible":true,"origin":"","legend":"","description":"","filename":"FinalFileBMCFinalManuscriptFIT.docx","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/54056d8faeee4a1de0fdd2f7.docx"},{"id":97674878,"identity":"2f7f1ee4-df01-468d-8914-7d5b97c73748","added_by":"auto","created_at":"2025-12-08 09:44:33","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10794,"visible":true,"origin":"","legend":"","description":"","filename":"d6afd6394ee14296ae9618fcecb76c71.json","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/cd1ae4ba69090627b0fdd4a6.json"},{"id":97654759,"identity":"a75e9cbc-603f-4cf6-ba18-d66e8b8a20ef","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101105,"visible":true,"origin":"","legend":"","description":"","filename":"d6afd6394ee14296ae9618fcecb76c711enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/2683de94dd1cc6bfdd6207e1.xml"},{"id":97654758,"identity":"11f97c61-5bd5-43bf-a406-40917c7dcc5d","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58847,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/a6e1f449dd1c153d207245ad.png"},{"id":97654765,"identity":"305ff3c2-f828-4206-a133-ace952a26031","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":110222,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/211cf34f7b9b148fe22803be.png"},{"id":97654753,"identity":"4d069e5d-18de-4c57-80b3-5fd1a4ddf6b1","added_by":"auto","created_at":"2025-12-08 07:02:18","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":19464,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/18563a63e7a9cd729525563a.png"},{"id":97654757,"identity":"d418b71c-0d9f-43aa-8a44-e959adb720bd","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":20932,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/edeae6a4de68bb90caf45585.png"},{"id":97654764,"identity":"1e3c8f6f-8163-461e-a1a2-f20979ec8788","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":207027,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/8affb4a04d8417e5b06b2b2a.png"},{"id":97654763,"identity":"8f5ab929-9dea-4703-ba4d-66dfcee9585b","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95866,"visible":true,"origin":"","legend":"","description":"","filename":"d6afd6394ee14296ae9618fcecb76c711structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/bc1c028ade72b0947b008ee0.xml"},{"id":97654762,"identity":"5d637fbb-f75f-4ec5-a6b7-33863e5ec8c8","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109087,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/29e0dcabdbf4d73a8bf952a4.html"},{"id":97654752,"identity":"71338c85-fb37-44f2-8a61-749c19cc38fa","added_by":"auto","created_at":"2025-12-08 07:02:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":265954,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of the FIT.\u003c/p\u003e\n\u003cp\u003e(a) Harvesting of the falciform ligament. (b and c) Placement of the falciform ligament dorsal to the pancreaticojejunostomy (PJ). (d) Drain placement in each separated area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eGDA, gastroduodenal artery; HJ, hepaticojejunostomy; PJ, pancreaticojejunostomy; RHA, right hepatic artery.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/086c0ffe90c35c0f6ec2b009.png"},{"id":97674509,"identity":"c9223bfb-fc3b-47f1-b29d-b9eb14780485","added_by":"auto","created_at":"2025-12-08 09:43:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":300237,"visible":true,"origin":"","legend":"\u003cp\u003eThe FIT.\u003c/p\u003e\n\u003cp\u003e(a) Placement of the falciform ligament dorsal to the pancreaticojejunostomy (PJ). (b) The gastroduodenal artery (GDA) stump covered with the falciform ligament.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eGDA, gastroduodenal artery; HJ, hepaticojejunostomy; PJ, pancreaticojejunostomy; RHA, right hepatic artery.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/2fb2d97f5bd07044dfc9a1d6.png"},{"id":97654754,"identity":"ca1907cf-4e98-4f30-8114-4798af8f1bca","added_by":"auto","created_at":"2025-12-08 07:02:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121755,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of participant selection.\u003c/p\u003e\n\u003cp\u003ePatients with portal annular pancreas who underwent 2-stage pancreatojejunostomy with complete external drainage, had insufficient falciform ligament volume, or underwent the procedure with FIT application were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviation:\u003c/strong\u003eFIT, falciform ligament interposition technique.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/b57f31ca893d9310f48a5744.png"},{"id":97672772,"identity":"8a1366a4-b6ec-4ede-9bb1-182c380eff0d","added_by":"auto","created_at":"2025-12-08 09:38:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":167956,"visible":true,"origin":"","legend":"\u003cp\u003eDrain amylase concentration and drain placement duration.\u003c/p\u003e\n\u003cp\u003e(a) Comparison of amylase concentration in drainage fluid on POD 3 (grades BL and B POPFs). The amylase concentration was significantly lower in the Area HJ drain than in the Area PJ drain (Wilcoxon signed-rank test for paired nonparametric data; \u003cem\u003ep\u003c/em\u003e =.009), confirming the functional efficacy of the interposed barrier in separating the 2 spaces. (b) Comparison of drain placement duration between the Area PJ and Area HJ groups. The drain placement period was significantly shorter for the Area HJ drain than for the Area PJ drain (Student t test for independent groups; \u003cem\u003ep\u003c/em\u003e\u0026lt;.001), demonstrating the clinical benefit of early drain removal from the vascular area. These findings support the physiological efficacy of the FIT-created 2-compartment system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eBL, biochemical leak; HJ, hepaticojejunostomy; IQR, interquartile range; PJ, pancreaticojejunostomy; POD, postoperative day.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/670d5337231f0eb9286cc47b.png"},{"id":97654761,"identity":"bf60950b-46f8-4e33-823a-5103ce44cacf","added_by":"auto","created_at":"2025-12-08 07:02:19","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":529735,"visible":true,"origin":"","legend":"\u003cp\u003eLocalized fluid collection and safe percutaneous drainage after the FIT.\u003c/p\u003e\n\u003cp\u003e(a) Contrast-enhanced CT image showing a localized pancreatic fluid collection (arrows) confined to the anterior space (Area PJ) by the anatomical partition created by the FIT. The collection formed superficially beneath the anterior abdominal wall without obstruction from underlying organs.\u003c/p\u003e\n\u003cp\u003e(b) Follow-up CT image showing complete resolution of the fluid collection after percutaneous drainage via the anterior abdominal wall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eCT, computed tomography; HJ, hepaticojejunostomy; PJ, pancreaticojejunostomy.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/70a971156abf9d87be68d3f8.jpeg"},{"id":104739363,"identity":"5c9ad292-7e6f-4296-9590-c11773f7a5c0","added_by":"auto","created_at":"2026-03-16 16:04:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2541317,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8105675/v1/afb06cb6-3975-4c78-a691-985aaf08883e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy","fulltext":[{"header":"Background","content":"\u003cp\u003ePancreaticoduodenectomy (PD) is one of the most complex abdominal surgeries, involving the resection and reconstruction of multiple organs and major vessels. Despite advances in surgical techniques and perioperative management, postoperative complications remain common. Among these, postoperative pancreatic fistula (POPF) represents a leading cause of morbidity and mortality \u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.When leakage of pancreatic juice is inadequately localized or poorly controlled, it can delay healing and precipitate serious complications, including infection and erosive hemorrhage from adjacent arteries or arterial stumps\u0026mdash;collectively known as postpancreatectomy hemorrhage (PPH). In severe cases, PPH can be life-threatening. Furthermore, Grade C POPF has been linked not only to poor short-term outcomes but also to unfavorable long-term prognosis \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo protect vascular structures from exposure to leaked pancreatic enzymes, several surgical strategies have been developed. These include wrapping the vessel stump with the omentum or falciform ligament \u003csup\u003e[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e and interposing the falciform ligament between the pancreatic anastomosis and hepatic arterial system \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. However, most previously reported methods have focused primarily on shielding the gastroduodenal artery (GDA) stump, without addressing the broader concept of functional compartmentalization.\u003c/p\u003e\u003cp\u003eAt our institution, we have refined and standardized this technique\u0026mdash;using the falciform ligament as an interposed, vascularized flap\u0026mdash;to establish what we term the Falciform Interposition Technique (FIT). This method was designed not only to protect arterial structures but also to achieve intentional and functional separation of the drainage spaces. The present study aimed to assess the clinical feasibility and outcomes of FIT in a large consecutive cohort. We hypothesized that this structural approach would facilitate localized control of pancreatic leakage, simplify postoperative drain management, and reduce the incidence of hemorrhagic complications following PD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient Selection\u003c/h2\u003e\u003cp\u003eAll consecutive patients who underwent PD at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan), between January 2018 and June 2024 were eligible for inclusion. Clinical data were obtained from institutional medical records and retrospectively reviewed.\u003c/p\u003e\u003cp\u003eAt our institution, PD is indicated for periampullary neoplasms\u0026mdash;including pancreatic, bile duct, ampullary, and duodenal cancers\u0026mdash;as well as selected benign or borderline lesions. Patients were excluded if they met any of the following criteria:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePresence of a portal annular pancreas;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTwo-stage pancreaticojejunostomy (PJ) with complete external drainage;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInadequate falciform ligament volume precluding performance of the FIT; or\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eUndergoing robotic PD, in which FIT was not applied because of technical limitations in the robotic setting.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Procedure\u003c/h3\u003e\n\u003cp\u003eAll patients underwent open or laparoscopy-assisted subtotal stomach-preserving PD with and without concomitant resection of the regional lymph nodes. The reconstruction procedure comprised a retro-colic jejunal loop with a PJ and hepaticojejunostomy (HJ). PJ included end-to-side duct-to-mucosa anastomosis with the modified Blumgart anastomosis technique \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. An internal stent was used when the main pancreatic duct (MPD) diameter was \u0026le;\u0026thinsp;4 mm. Gastrojejunostomy was performed using ante-colic Billroth II anastomosis without Braun anastomosis (modified Child\u0026rsquo;s reconstruction). In laparoscopy-assisted cases, digestive reconstruction was performed through a small laparotomy incision.\u003c/p\u003e\n\u003ch3\u003eFIT(Falciform ligament interposition technique)\u003c/h3\u003e\n\u003cp\u003eThe round ligament was divided near the umbilicus and carefully dissected along the posterior surface of the rectus sheath toward the undersurface of the diaphragm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). The surrounding preperitoneal fat was preserved as much as possible to maintain vascularity. The falciform ligament was then divided near the Glisson\u0026rsquo;s sheath at the hepatic hilum, producing a vascularized, pennant-shaped flap (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAfter completion of the reconstructive phase, the harvested falciform ligament was positioned between the PJ and the hepatic artery to create a physical barrier and achieve spatial separation of these structures (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For descriptive clarity, the space superior to the interposed falciform ligament\u0026mdash;surrounding the PJ\u0026mdash;was designated as \u0026ldquo;Area PJ,\u0026rdquo; whereas the space inferior to the ligament\u0026mdash;around the hepatic artery\u0026mdash;was designated as \u0026ldquo;Area HJ.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTwo closed-suction drains were placed intraoperatively: the Area PJ drain was positioned dorsal to the PJ, and the Area HJ drain was placed dorsal to the HJ (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed).\u003c/p\u003e\n\u003ch3\u003ePostoperative Drain Management\u003c/h3\u003e\n\u003cp\u003eAs part of standardized postoperative care, the amylase concentration in the drainage fluid from each site was measured on postoperative day (POD) 3. Drains were removed when the amylase level in the effluent was \u0026lt;\u0026thinsp;400 IU/L. If the concentration exceeded 400 IU/L, the drain was retained until the fistula resolved or drainage volume markedly decreased. When intra-abdominal fluid collections suggestive of infection were detected, additional percutaneous drainage was performed to ensure adequate evacuation.\u003c/p\u003e\n\u003ch3\u003eDefinition of Morbidity and Mortality\u003c/h3\u003e\n\u003cp\u003ePOPF was defined according to the 2016 criteria of the International Study Group on Pancreatic Fistula (ISGPF) \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Grade B and C POPFs were classified as clinically relevant. PPH was defined based on the criteria of the International Study Group of Pancreatic Surgery (ISGPS) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. According to these criteria, late extraluminal mild hemorrhage is categorized as Grade B because it may serve as a sentinel event indicating potential for severe bleeding. In this study, Grades B and C hemorrhages were considered PPH.\u003c/p\u003e\u003cp\u003ePostoperative mortality was defined as death occurring within 90 days after surgery or during the index hospitalization.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis\u003c/h2\u003e\u003cp\u003eAll patients underwent preoperative and postoperative evaluations, including clinical history, physical examination, serum laboratory testing, and pancreatic protocol computed tomography (CT). Amylase concentrations in the drainage fluid were compared between Area PJ and Area HJ in patients who developed POPF. The duration of drain placement was also compared between the two drain sites.\u003c/p\u003e\u003cp\u003ePostoperative outcomes, including morbidity, mortality, length of hospital stay, duration of drain placement, and insertion sites of additional drains in patients with Grade B POPF, were systematically analyzed.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eAll statistical analyses were performed using JMP Pro, version 17.0.0 (SAS Institute Inc., Cary, NC, USA). Continuous variables were expressed as medians with interquartile ranges, and categorical variables as frequencies and percentages. Paired \u003cem\u003et\u003c/em\u003e-tests were used to compare paired continuous measurements. A two-sided \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003cp\u003ewas obtained in the form of opt-out on the website. All of the patients provided informed consent for the use of their data in our research. The study protocol was approved by the Institutional Review Board of Osaka Medical and Pharmaceutical University (approval number: 2023\u0026thinsp;\u0026minus;\u0026thinsp;217, March 18, 2023). Moreover, the study was conducted following the guidelines stipulated in the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 238 patients underwent PD at our institution between January 2018 and June 2024. Of these, nine patients were excluded from the analysis according to the study criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): two with portal annular pancreas, one who underwent two-stage pancreatojejunostomy with complete external drainage, four in whom the falciform ligament volume was insufficient for the FIT, and two who underwent robotic PD, in which the technique could not be applied.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics and Operative Details\u003c/h2\u003e\u003cp\u003eThe median patient age was 72 years (interquartile range [IQR], 66\u0026ndash;77 years); 130 were men and 99 were women. The median body mass index (BMI) was 22.1 kg/m\u0026sup2; (IQR, 19.8\u0026ndash;24.4) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients\u0026rsquo; characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics and Factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEntire Cohort (n\u0026thinsp;=\u0026thinsp;229)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72[66\u0026ndash;77]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male/Female), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130(57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, kg/m\u0026sup2;, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.1[19.8\u0026ndash;24.4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistopathological Findings, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic ducal adenocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (34.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResectable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorderline resectable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocally advanced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholangiocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (21.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmpullary carcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (13.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuodenal carcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (4.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetastatic pancreatic tumor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0.87)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPMC (invasive carcinoma)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPMN (LGD, HGD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (10.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNEN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (4.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenign tumor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Factor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time, min, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e440 [387\u0026ndash;501]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss, g, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e370 [220\u0026ndash;580]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of Surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e177 (77.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLaparoscopic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (22.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRobotic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Findings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiameter of MPD, mm, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4[3\u0026ndash;5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic texture (soft/hard), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e139/90 (61/39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eBMI, body mass index; HGD, high-grade dysplasia; IPMC, intraductal papillary mucinous carcinoma; IPMN, intraductal papillary mucinous neoplasm; IQR, interquartile range; LGD, low-grade dysplasia; MPD, main pancreatic duct; NEN, neuroendocrine neoplasm.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHistopathological examination revealed malignant tumors in 187 patients (81.7%). Among patients with pancreatic cancer, 49 (59.8%) had resectable, 30 (36.6%) had borderline resectable, and one (1.2%) had locally advanced cancer, as defined by the International Association of Pancreatology classification of anatomical resectability \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eOperative Procedures and Findings\u003c/h2\u003e\u003cp\u003eLaparoscopy-assisted PD was performed in 52 patients (22.7%). The median operative time was 440 minutes (IQR, 387\u0026ndash;501 minutes), and the median intraoperative blood loss was 370 mL (IQR, 220\u0026ndash;580 mL). The median MPD diameter was 4 mm (IQR, 3\u0026ndash;5 mm). Pancreatic texture was soft in 139 patients (61%) and hard in 90 patients (39%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDrain Amylase Concentrations, Drain Management, and POPF\u003c/h2\u003e\u003cp\u003eOn POD 3, the median amylase concentration in the entire cohort was 255 IU/L (interquartile range [IQR], 14\u0026ndash;1621 IU/L) in the Area PJ drain and 74 IU/L (IQR, 9\u0026ndash;247 IU/L) in the Area HJ drain, showing a significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These data, although not included in figures or tables, are provided here for completeness.\u003c/p\u003e\u003cp\u003eAmong patients who developed POPF Grades biochemical leak [BL], B, or C; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;102), the median POD3 amylase concentration was also significantly lower in the Area HJ drains than in the Area PJ drains\u0026mdash;233 IU/L (IQR, 74\u0026ndash;907 IU/L) versus 1619 IU/L (IQR, 660\u0026ndash;4255 IU/L), respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea). When the amylase concentration in the Area HJ drain was low, it was removed earlier than the Area PJ drain, enabling simplified postoperative management with a single drain.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the Grade BL and B POPF cohorts, the median durations of drain placement were 23 days for the Area PJ drain and 7 days for the Area HJ drain (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb). Among patients with Grade B POPF, 24 (49.0%) required additional percutaneous drainage. In all such cases, additional drains were safely and easily inserted through the anterior abdominal wall, as the fluid collection was localized around the PJ site (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMorbidities and Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eorbidities and Outcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEntire cohort (n\u0026thinsp;=\u0026thinsp;229)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOPF, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade BL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (23.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49 (21.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdditional drain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (10.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrainage route(anterior abdomen/others)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24/0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersisting drainage\u0026thinsp;\u0026gt;\u0026thinsp;3 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(9.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAngiographic procedures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(1.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrgan failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePPH, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(3.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePSA (GDA stump)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGDA stump without PSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransverse pancreatic artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJejunal artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSentinel bleeding (unknown origin)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative Hospital Stay, day, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEntire cohort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 [14\u0026ndash;33]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade BL POPF cohort (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24[18\u0026ndash;31]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade B POPF cohort (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35[29\u0026ndash;43]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo POPF cohort (n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15[12\u0026ndash;23]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eBL, biochemical leak; GDA, gastroduodenal artery; IQR, interquartile range; POPF, postoperative pancreatic fistula (POPF); PPH, postpancreatectomy hemorrhage; PSA, pseudoaneurysm.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe median postoperative hospital stay was 23 days in the overall cohort, 24 days in the Grade BL POPF cohort, 35 days in the Grade B POPF cohort, and 15 days in patients without POPF. The incidences of Grade B and C POPF were 21.4% (49 cases) and 0.9% (2 cases), respectively.\u003c/p\u003e\u003cp\u003eA total of eight patients (3.5%) developed PPH (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Major bleeding occurred in six cases (Cases 1\u0026ndash;6). Among these, two cases (0.9%) (Cases 1 and 2) were due to pseudoaneurysm rupture at the GDA stump following POPF, diagnosed by contrast-enhanced CT or angiography. Two cases (Cases 3 and 4) involved bleeding from a transverse pancreatic artery, with Case 4 presenting within 24 hours postoperatively, suggesting no relation to POPF. Two additional cases (Cases 5 and 6) were attributed to intraoperative hemostatic failure\u0026mdash;one (Case 5) associated with locally advanced pancreatic cancer invading the GDA root, and the other (Case 6) with jejunal arterial injury. Case 5 experienced fatal GDA stump hemorrhage on POD 21. Neither of these hemostasis-related cases developed POPF. The remaining two patients (Cases 7 and 8) exhibited minor sentinel bleeding that did not progress to major hemorrhage.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of cases with PPH\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase No\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType Of Hemorrhage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTiming of Bleeding\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrain Amylase (IU/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDrain Amylase (IU/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDrain Amylase (IU/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDrain Amylase (IU/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eProcedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eMortality\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(POD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePJ, POD3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHJ, POD3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePJ, POD7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHJ, POD7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSA (GDA\u0026rsquo;s stump)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1439\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e690\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR, reoperation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSA (GDA\u0026rsquo;s stump)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e131600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransverse pancreatic artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/A(already removed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN/A(already removed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransverse pancreatic artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e973\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInappropriate hemostat (GDA)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e335\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInappropriate hemostat (Jejunal artery)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e767\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSentinel bleeding (unknown origin)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN/A(already removed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSentinel bleeding (unknown origin)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e234300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1756\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e91388\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eGDA, gastroduodenal artery; HJ, hepaticojejunostomy; IVR, interventional radiology; N/A, not applicable; PJ, pancreaticojejunostomy; POD, postoperative day; PPH, postpancreatectomy hemorrhage; PSA, pseudoaneurysm.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePOPF remains a major complication after PD and can lead to life-threatening PPH. To enhance postoperative drainage management and minimize the risk of PPH, our institution adopted the \u003cstrong\u003eFIT\u003c/strong\u003e, which uses the falciform ligament as an interposed flap to establish both physical and functional separation between the PJ and the hepatic artery systems.\u003c/p\u003e\n\u003cp\u003eIn this single-institution retrospective study of \u003cstrong\u003e229 consecutive patients\u003c/strong\u003e who underwent PD with FIT, we evaluated postoperative outcomes, including drain-related parameters, POPF, and PPH. The median amylase concentration on POD 3 was significantly lower in the Area HJ drains than in the Area PJ drains (\u003cem\u003ep\u003c/em\u003e = 0.009), confirming effective functional compartmentalization. Among patients with Grade BL and Grade B POPF, the drain placement period was also markedly shorter in the Area HJ drains (7 days) than in the Area PJ drains (23 days) (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). In Grade B POPF, additional percutaneous drainage could be safely performed via the anterior abdominal wall, as FIT effectively localized the fluid collection to a superficial layer. Clinically relevant POPF (Grades B and C) and PPH occurred in \u003cstrong\u003e22.3%\u003c/strong\u003e and \u003cstrong\u003e3.5%\u003c/strong\u003e of patients, respectively. PPH due to pseudoaneurysm formation at the GDA stump was observed in \u003cstrong\u003etwo cases (0.9%)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eCollectively, these findings indicate that FIT offers an effective and feasible approach to postoperative drainage control while maintaining structural and functional separation between the hepatic artery and PJ. This separation confers three principal clinical benefits:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Early drain removal and simplified single-drain care:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eA pronounced amylase gradient allows early removal of the Area HJ drain, enabling streamlined management with a single Area PJ drain (Fig.\u0026nbsp;4). This approach simplifies postoperative care, enhances patient comfort, facilitates early mobilization, and promotes infection control and fistula maturation.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eLocalized control and safer intervention:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eBy confining pancreatic leakage to the Area PJ, FIT enables straightforward and safe percutaneous drainage through the anterior abdominal wall, minimizing the risk of injury to adjacent organs. Complete clearance of infected fluid was achieved in all cases requiring intervention (Fig. 5). As reported previously, bacterial infection is a key factor in the development of Grade B and C POPFs \u003csup\u003e[15–18]\u003c/sup\u003e; thus, effective localized drainage remains essential for infection control.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eStructural protection of major arteries:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFIT serves as a mechanical barrier that prevents arterial erosion, particularly of the hepatic artery system and GDA stump, thereby reducing the risk of delayed hemorrhage.\u003c/p\u003e\n\u003cp\u003ePrevious studies have reported a PPH incidence of \u003cstrong\u003e2%–10%\u003c/strong\u003e following PD \u003csup\u003e[19–22]\u003c/sup\u003e. In the present series, PPH occurred in \u003cstrong\u003e3.5%\u003c/strong\u003e of patients, with only \u003cstrong\u003etwo cases (0.9%)\u003c/strong\u003e attributable to pseudoaneurysm rupture at the GDA stump following POPF—the precise event that FIT is designed to prevent. Although several earlier reports described wrapping vessel stumps with omentum or the falciform ligament to protect the GDA stump \u003csup\u003e[9,10]\u003c/sup\u003e, those methods focused solely on hemostatic reinforcement. In contrast, the \u003cstrong\u003ecore innovation of FIT\u003c/strong\u003e lies in its deliberate creation of a \u003cstrong\u003etwo-compartment drainage system\u003c/strong\u003e, combining vessel protection with controlled compartmentalization.\u003c/p\u003e\n\u003cp\u003eIt is acknowledged that amylase concentrations in drains placed anatomically distant from the PJ—such as those near the HJ—may occasionally be lower even without an interposed barrier. However, this natural separation is often inconsistent and limited in effect. The FIT converts this passive anatomical relationship into an \u003cstrong\u003eintentional and reproducible compartmentalization strategy\u003c/strong\u003e, ensuring consistent physiological separation. The \u003cstrong\u003elarge and consistent amylase gradient\u003c/strong\u003e observed in our study provides quantitative evidence that FIT reinforces this separation, resulting in predictable drainage behavior and a safer postoperative environment.\u003c/p\u003e\n\u003cp\u003eTaken together, our findings underscore both the \u003cstrong\u003econceptual and practical significance\u003c/strong\u003e of FIT. It is not merely a technical refinement but a \u003cstrong\u003erational, physiology-based framework\u003c/strong\u003e for safer and more efficient postoperative management after PD.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. It was a retrospective, single-arm cohort analysis without a control group of patients who underwent PD without FIT. Therefore, definitive conclusions regarding comparative efficacy cannot be drawn. Nevertheless, the large, consecutive cohort provides substantial evidence supporting the procedural safety and mechanistic validity of FIT. Although the observed amylase gradient demonstrates functional separation, confirming its effect on hemorrhagic outcomes and long-term prognosis will require prospective, multicenter comparative studies. Future research comparing FIT with conventional drainage techniques is warranted to validate its clinical value and optimize postoperative strategies after PD.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe FIT is an effective and reproducible approach that establishes a robust structural barrier between the PJ and the hepatic arterial system, including the GDA stump. The pronounced amylase gradient observed between the two drainage areas quantitatively demonstrates the functional separation achieved by the interposed falciform ligament. This configuration facilitates early and rational drain removal, streamlines postoperative management of pancreatic fistula through single-drain control and localized infection management, and may reduce the risk of hemorrhagic complications, including pseudoaneurysm formation at the GDA stump. Overall, these findings support FIT as a practical, physiologically grounded, and structurally rational strategy for safer and more efficient postoperative management following PD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIf abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided.\u003c/p\u003e\n\u003cp\u003ePD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pancreaticoduodenectomy\u003c/p\u003e\n\u003cp\u003ePOPF\u0026nbsp; \u0026nbsp;Postoperative pancreatic fistula\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPH\u0026nbsp; \u0026nbsp; \u0026nbsp;Postpancreatectomy hemorrhage\u003c/p\u003e\n\u003cp\u003eFIT\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Falciform Interposition Technique\u003c/p\u003e\n\u003cp\u003ePJ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pancreaticojejunostomy\u003c/p\u003e\n\u003cp\u003eHJ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hepaticojejunostomy\u003c/p\u003e\n\u003cp\u003eGDA\u0026nbsp; \u0026nbsp;\u0026nbsp;Gastroduodenal artery\u003c/p\u003e\n\u003cp\u003ePOD\u0026nbsp; \u0026nbsp;\u0026nbsp;Postoperative day\u003c/p\u003e\n\u003cp\u003eBL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Biochemical leak\u003c/p\u003e\n\u003cp\u003ePSA\u0026nbsp; \u0026nbsp; \u0026nbsp;Pseudoaneurysm\u003c/p\u003e\n\u003cp\u003eRPD\u0026nbsp; \u0026nbsp;\u0026nbsp;Robotic Pancreaticoduodenectomy\u003c/p\u003e\n\u003cp\u003eMPD\u0026nbsp; \u0026nbsp;\u0026nbsp;Main pancreatic duct\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; Computed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Institutional Review Board of Osaka Medical and Pharmaceutical University (approval No. 2023-217; March 18, 2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained through an opt-out procedure posted on the institutional website.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding, grants, or other financial support was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAtsushi Tomioka: Writing\u0026mdash;original draft.\u003cbr\u003e\u0026nbsp;Nao Kawaguchi: Conceptualization.\u003cbr\u003e\u0026nbsp;Yasuhiko Ueda: Investigation.\u003cbr\u003e\u0026nbsp;Shuhei Kushiyama: Data curation.\u003cbr\u003e\u0026nbsp;Koji Komeda: Methodology.\u003cbr\u003e\u0026nbsp;Mitsuhiro Asakuma: Writing\u0026mdash;review and editing.\u003cbr\u003e\u0026nbsp;Hideki Tomiyama: Visualization.\u003cbr\u003e\u0026nbsp;Yoshiharu Miyamoto: Supervision.\u003cbr\u003e\u0026nbsp;Sang-Woong Lee: Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Enago (www.enago.jp) for providing English language editing assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAtsushi Tomioka, MD, PhD, is an Associate Professor in the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, specializing in pancreatic and biliary surgery.\u003cbr\u003e All authors are staff surgeons in the same department with clinical expertise in hepatobiliary-pancreatic surgery. They are members of the Japanese Society of Hepato-Biliary-Pancreatic Surgery and/or the Japan Surgical Society.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAoki S, Miyata H, Konno H, Gotoh M, Motoi F, Kumamaru H, et al. Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan. J Hepatobil Pancreat Sci. 2017;24:243\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jhbp.438\u003c/span\u003e\u003cspan address=\"10.1002/jhbp.438\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimon R. Complications after pancreaticoduodenectomy. Surg Clin North Am. 2021;101:865\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.suc.2021.06.011\u003c/span\u003e\u003cspan address=\"10.1016/j.suc.2021.06.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMirrielees JA, Weber SM, Abbott DE, Greenberg CC, Minter RM, Scarborough JE. Pancreatic fistula and delayed gastric emptying are the highest-impact complications after whipple. J Surg Res. 2020;250:80\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jss.2019.12.041\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2019.12.041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKawai M, Murakami Y, Motoi F, Sho M, Satoi S, Matsumoto I, et al. Grade B pancreatic fistulas do not affect survival after pancreatectomy for pancreatic cancer: a multicenter observational study. Surgery. 2016;160:293\u0026ndash;305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2016.02.032\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2016.02.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRamia JM, de la Plaza R, Adel F, Ramiro C, Arteaga V, Garcia-Parre\u0026ntilde;o J. Wrapping in pancreatic surgery: a systematic review. ANZ J Surg. 2014;84:921\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ans.12491\u003c/span\u003e\u003cspan address=\"10.1111/ans.12491\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWerey F, Browet F, Mauvais F. Falciform ligament wrap during laparoscopic pancreatoduodenectomy. J Visc Surg. 2019;156:50\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jviscsurg.2018.11.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jviscsurg.2018.11.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, et al. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB. 2020;22:1227\u0026ndash;39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.hpb.2020.05.003\u003c/span\u003e\u003cspan address=\"10.1016/j.hpb.2020.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarique L, Codjia T, Sauvanet A. Retromesenteric omental flap for complete arterial coverage during pancreaticoduodenectomy: surgical technique. World J Surg. 2022;46:2440\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-022-06641-7\u003c/span\u003e\u003cspan address=\"10.1007/s00268-022-06641-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOkada K, Murakami Y, Uemura K, Kondo N, Nakagawa N, Seo S, et al. Flooring the major vessels with falciform ligament to prevent post-pancreatectomy hemorrhage. World J Surg. 2020;44:3478\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-020-05637-5\u003c/span\u003e\u003cspan address=\"10.1007/s00268-020-05637-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbe N, Sugiyama M, Suzuki Y, Yanagida O, Masaki T, Mori T, et al. Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels. J Hepatobiliary Pancreat Surg. 2009;16:184\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00534-008-0036-8\u003c/span\u003e\u003cspan address=\"10.1007/s00534-008-0036-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFujii T, Sugimoto H, Yamada S, Kanda M, Suenaga M, Takami H, et al. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical Control Study J. J Gastrointest Surg. 2014;18:1108\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11605-014-2523-3\u003c/span\u003e\u003cspan address=\"10.1007/s11605-014-2523-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBassi 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. 2019;161:584\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2016.11.014\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2016.11.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH)-an international study group of pancreatic surgery (ISGPS) definition. Surgery. 2007;142:20\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2007.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2007.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsaji S, Mizuno S, Windsor JA, Bassi C, Fern\u0026aacute;ndez-Del Castillo C, Hackert T, et al. International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017. Pancreatology. 2018;18:2\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pan.2017.11.011\u003c/span\u003e\u003cspan address=\"10.1016/j.pan.2017.11.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChiba N, Ochiai S, Yokozuka K, Gunji T, Sano T, Tomita K, et al. Risk factors for life-threatening grade c postoperative pancreatic fistula after pancreatoduodenectomy compared to grade B. Anticancer Res. 2019;39:2199\u0026ndash;205. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21873/anticanres.13335\u003c/span\u003e\u003cspan address=\"10.21873/anticanres.13335\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi GQ, Zhang T, Yang WG, Zhong HL, Xiao P, Liu LW, et al. Gut microbiota patterns associated with somatostatin in patients undergoing pancreaticoduodenectomy: a prospective study. Cell Death Discov. 2020;6:94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41420-020-00329-4\u003c/span\u003e\u003cspan address=\"10.1038/s41420-020-00329-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLangheinrich M, Wirtz S, Kneis B, Gittler MM, Tyc O, Schierwagen R, et al. Microbiome patterns in matched bile, duodenal, pancreatic tumor tissue, drainage, and stool samples: association with preoperative stenting and postoperative pancreatic fistula development. J Clin Med. 2020;9:2785. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm9092785\u003c/span\u003e\u003cspan address=\"10.3390/jcm9092785\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXiang C, Chen Y, Liu X, Zheng Z, Zhang H, Tan C. Prevention and treatment of grade c postoperative pancreatic fistula. J Clin Med. 2022;11:7516. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm11247516\u003c/span\u003e\u003cspan address=\"10.3390/jcm11247516\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYeo 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;226:248\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-199709000-00004\u003c/span\u003e\u003cspan address=\"10.1097/00000658-199709000-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg. 1998;227:236\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-199802000-00013\u003c/span\u003e\u003cspan address=\"10.1097/00000658-199802000-00013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg. 2004;199:186\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jamcollsurg.2004.04.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jamcollsurg.2004.04.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhuri S, Mansour S, Obeid A, Azzam A, Borzellino G, Kluger Y. Postpancreatoduodenectomy hemorrhage: association between the causes and the severity of the bleeding. Visc Med. 2021;37:171\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000509894\u003c/span\u003e\u003cspan address=\"10.1159/000509894\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Falciform ligament, Pancreaticoduodenectomy, Postoperative pancreatic fistula, Interposition flap, Drainage management","lastPublishedDoi":"10.21203/rs.3.rs-8105675/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8105675/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Postoperative pancreatic fistula (POPF) is a major complication followingpancreaticoduodenectomy (PD) and is often associated with delayed recovery and postoperative hemorrhage (PPH). The falciform ligament interposition technique (FIT) employs the falciform ligament as a vascularized flap positioned between the pancreaticojejunostomy (PJ) and the hepatic artery. This approach provides a mechanical barrier and enables functional separation of the drainage spaces, potentially reducing the risk of POPF-related PPH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective study included all consecutive patients who underwent PD at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan) between January 2018 and June 2024. Postoperative outcomes, including drain-related variables, incidence of POPF, and occurrence of PPH, were systematically analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 229 patients who underwent PD with the FIT, the median amylase concentration on postoperative day (POD) 3 was significantly lower in the hepaticojejunostomy (HJ) drain compared with the PJ drain (74 vs. 255 IU/L, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn the subgroup of 102 patients who developed POPF; Grades biochemical leak [BL], B, or C), the median POD 3 amylase concentration in the HJ drain remained significantly lower than that in the PJ drain (233 vs. 1,619 IU/L, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), confirming effective compartmentalization of the drainage spaces.\u003c/p\u003e\n\u003cp\u003eAmong patients with Grade B POPF, 24 (49.0%) required additional percutaneous drainage, which was safely and easily performed via the anterior abdominal wall because the fluid collection was confined to the PJ site immediately beneath it. Postpancreatectomy hemorrhage (PPH) originating from the gastroduodenal artery (GDA) stump occurred in two patients (0.9%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis compartmentalization strategy yielded three major clinical advantages:\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eEarly drain removal and \u003c/strong\u003esimplified single-drain care\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eLocalized control and safer interventionl\u003c/strong\u003e—allowing efficient infection control, and\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eStructural protection of major arteries \u003c/strong\u003e—reducing arterial exposure to pancreatic enzymes and thereby minimizing the risk of PPH from the GDA stump.\u003c/p\u003e\n\u003cp\u003eThe consistently marked amylase gradient observed between the PJ and HJ drains provides quantitative evidence that FIT promotes effective physiological separation, ensuring predictable drainage behavior and a safer postoperative environment. Collectively, these findings support FIT as a practical, physiologically sound, and structurally rational approach for postoperative management following PD.\u003c/p\u003e","manuscriptTitle":"Falciform Ligament Interposition Technique: An Optimized Drainage Strategy After Pancreaticoduodenectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 07:02:14","doi":"10.21203/rs.3.rs-8105675/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-29T07:35:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-26T14:16:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-24T14:45:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T22:32:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T13:52:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T06:32:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T17:05:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T12:53:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T10:46:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-11T09:04:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-09T07:29:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T07:36:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T07:16:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307092307970688982354894578079856872911","date":"2025-12-07T18:26:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T07:45:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-06T07:46:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50470398449121828991602874784193289753","date":"2025-12-05T23:35:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152546426885723172641827142000506172609","date":"2025-12-05T14:51:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117239679494736663580894406143042128635","date":"2025-12-05T09:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37597617042604031923260677786500963548","date":"2025-12-05T09:10:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316073680049767027754161980084925576267","date":"2025-12-05T05:29:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129440362865191415752309070401204364782","date":"2025-12-05T01:59:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194100115321232440891283531931716928395","date":"2025-12-04T18:30:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146266577095053285309055395967440821818","date":"2025-12-04T05:28:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239612058939647049910442757177115014505","date":"2025-12-04T00:39:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113580032321652137714905233460781685471","date":"2025-12-03T17:20:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48959655199457318270853345035806116623","date":"2025-12-03T10:49:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61978262887066686797864747862106992106","date":"2025-12-03T07:49:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161235924980171238940591698668747028711","date":"2025-12-03T06:05:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176760551470566742337329942699640934870","date":"2025-12-03T04:53:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177371005220310109171617255571133565515","date":"2025-12-03T03:03:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309901254319899145946679931718748731605","date":"2025-12-02T22:12:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242079798073552228802659110222639718224","date":"2025-12-02T21:31:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66442380249548320159291917535598870853","date":"2025-12-02T21:13:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325097647056951126315368852161000134396","date":"2025-12-02T18:24:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149986411414267377721522316169136319353","date":"2025-12-02T18:09:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-02T18:03:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-20T09:11:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-18T06:54:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T06:54:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-11-13T12:20:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"65d98d35-4aca-4013-bd17-18251c665b63","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:01:56+00:00","versionOfRecord":{"articleIdentity":"rs-8105675","link":"https://doi.org/10.1186/s12893-026-03661-1","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-13 15:58:14","publishedOnDateReadable":"March 13th, 2026"},"versionCreatedAt":"2025-12-08 07:02:14","video":"","vorDoi":"10.1186/s12893-026-03661-1","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03661-1","workflowStages":[]},"version":"v1","identity":"rs-8105675","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8105675","identity":"rs-8105675","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}