Afferent Loop Decompression and Outcomes After Pancreaticoduodenectomy: Hybrid Cohort with Propensity Score Matching

Afferent Loop Decompression and Outcomes After Pancreaticoduodenectomy: Hybrid Cohort with Propensity Score Matching | 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 Afferent Loop Decompression and Outcomes After Pancreaticoduodenectomy: Hybrid Cohort with Propensity Score Matching Dipen Patel, Jyotirmay Jena, Sumit Subhadarshi Mohanty, Pratik Bhagat, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8354959/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Clinically relevant postoperative pancreatic fistula (CR‑POPF) remains a key driver of morbidity after pancreaticoduodenectomy (PD). Afferent loop decompression (ALD) has been proposed to lower intraluminal pressure and reduce the risk of pancreatojejunostomy leak. Methods We conducted a study at a single HPB unit (August 2024–July 2025) with a prospective cohort of 20 consecutive ALD cases compared with 60 propensity score matched historical controls. All the patients included in the study underwent Pylorus Resecting pancreaticoduodenectomy (PRPD) with Pancreaticojejunostomy anastomosis by modified Blumgart technique. Primary outcome was CR‑POPF (ISGPS Grade B/C). Secondary outcomes included delayed gastric emptying (DGE), post‑pancreatectomy hemorrhage (PPH), bile leak, and length of hospital stay. Results Incidence of CR‑POPF was lower in the ALD group (10% vs 20%), however it was not statistically significant. Notably, grade B DGE occurred in 0% of ALD vs 46.7% of non‑ALD patients, and a significantly shorter length of hospital stay (12.2 vs 16.3 days, p < 0.001). PPH and bile leak occurred only among non-ALD patients, though events were infrequent. On univariate analysis, higher CA19‑9 (log‑transformed), BMI, and COPD/bronchial asthma were associated with increased odds of CR‑POPF. Conclusions In this preliminary matched analysis, ALD was associated with markedly lower DGE and length of hospital stay. However, the reduction in CR-POPF did not reach statistical significance. Pancreaticoduodenectomy Afferent loop decompression POPF Postoperative complication Pancreatic malignancy Figures Figure 1 Figure 2 Figure 3 Introduction Pancreaticoduodenectomy (PD) remains the definitive surgical intervention for periampullary malignancies and selected benign conditions involving pancreatic head and distal bile duct. 1 , 2 Despite substantial reductions in operative mortality with increasing surgical centralization and perioperative optimization, PD continues to be associated with a high burden of postoperative morbidity, reported in up to one-third to one-half of patients even in specialized centers. 1 – 4 Among postoperative complications, clinically relevant postoperative pancreatic fistula (CR-POPF) represents a major determinant of adverse outcomes following PD. 5 The risk of CR-POPF is influenced by a combination of patient-related, gland-related, and operative factors, including pancreatic texture, duct diameter, intraoperative blood loss, preoperative biliary stenting, nutritional status and systemic comorbidities. 5 , 6 Although multiple technical modifications and adjunctive measures have been proposed to mitigate fistula formation - such as variations in pancreatoenteric anastomosis, pharmacological suppression of pancreatic secretion, and drain management strategies - no single intervention has demonstrated consistent benefit across diverse risk profiles. 7 , 8 An often-underrecognized contributor to early postoperative morbidity after PD is altered physiology within the reconstructed jejunal limb. Postoperative edema, ileus, or kinking of the afferent limb may impair effective drainage of pancreatic and biliary secretions, resulting in elevated intraluminal pressure across the pancreatojejunostomy (PJ) and hepaticojejunostomy (HJ). This mechanical stress, particularly in the early postoperative period, may predispose to anastomotic leakage and exacerbate downstream complications such as delayed gastric emptying (DGE) and postoperative cholangitis. 9 – 11 Afferent loop decompression (ALD) has been proposed as a simple intraoperative strategy to facilitate early postoperative drainage of biliopancreatic secretions by providing controlled decompression of the afferent jejunal limb. Unlike reconstructive modifications that introduce additional anastomoses, ALD aims to reduce intraluminal pressure without altering gastrointestinal continuity. Previous reports evaluating jejunal or biliary decompression techniques after PD have been limited by heterogeneous methodologies, small sample sizes, and non-randomized designs, with variable effects reported on pancreatic fistula and gastric emptying outcomes. 12 Given the continued uncertainty surrounding the role of decompressive strategies in reducing PD-related morbidity, further evaluation of ALD in contemporary surgical practice is warranted. Using a hybrid cohort design with prospective enrollment of ALD cases and propensity score matched historical controls, we aimed to examine the association of ALD with CR-POPF, DGE, post-pancreatectomy hemorrhage (PPH), bile leak, and length of hospital stay. Materials and Methods Study design and setting This study was conducted at a tertiary care hepatopancreatobiliary (HPB) referral centre in eastern India. A hybrid cohort design was employed, comprising a prospectively enrolled intervention group undergoing ALD during pylorus resecting pancreaticoduodenectomy (PRPD) and a retrospectively identified control group of patients who underwent PRPD without ALD at the same institution. Study population Adult patients (≥ 18 years) undergoing PRPD were eligible for inclusion. The prospective ALD cohort consisted of consecutive patients operated between August 2024 and July 2025. The control cohort was derived from patients who underwent PRPD without ALD during the four years preceding the study period. Patients who had accidental removal of the decompression tube in the postoperative period were excluded. None of the patients in either cohort received neoadjuvant chemotherapy or chemoradiotherapy. The Study flow diagrams for both cohorts are depicted in Figs. 1 and 2 . Ethical approval and trial registration The study protocol was approved by the Institutional Ethics Committee of the Institute of Medical Sciences and SUM Hospital (IEC Registration No: ECR/627/Inst/OR/2014/RR-20). Written informed consent was obtained from all prospectively enrolled participants. The study was registered with the Clinical Trial Registry of India (CTRI/2025/12/098589) and was conducted in accordance with the Declaration of Helsinki. Surgical technique and afferent loop decompression All patients underwent open PRPD performed by one of two senior HPB surgeons with extensive experience in pancreatic surgery. Reconstruction was standardized across both cohorts and consisted of PJ (modified Blumgart technique), HJ, antecolic gastrojejunostomy (GJ), and feeding jejunostomy (FJ) (Witzel technique). In the ALD group, afferent loop decompression was achieved intraoperatively by advancing a 16-Fr Ryle’s tube into the afferent jejunal limb to a position within approximately 5 cm distal to the HJ, following completion of the posterior layer of the GJ. (Fig. 3 ) The tube was allowed to drain freely postoperatively and was typically removed on postoperative day five, unless DGE necessitated prolonged decompression. In the control group, a 16-Fr Ryle’s tube was positioned in the stomach as per standard practice. Postoperative feeding protocols were uniform across both cohorts. Oral clear liquids were initiated from postoperative day four in the absence of DGE, with FJ support used as required. Propensity score matching To minimize selection bias, patients in the ALD cohort were matched in a 1:3 ratio with controls using nearest neighbour propensity score matching without replacement. Matching variables included age, sex, preoperative biliary drainage, pancreatic duct diameter, pancreatic texture, and intraoperative blood loss. Standardized mean differences were assessed to evaluate adequacy of matching. The Fistula Risk Score (FRS) was calculated for all patients using pancreatic texture, duct diameter, pathology, and intraoperative blood loss. Outcomes and definitions The primary outcome was the incidence of CR-POPF, defined as ISGPS grade B or C fistula. Secondary outcomes included DGE, post-pancreatectomy haemorrhage (PPH), bile leak, postoperative morbidity, and length of hospital stay. Postoperative complications were classified according to established international definitions: CR-POPF, DGE, and PPH were graded using ISGPS criteria 13 ; bile leak was defined according to ISGLS guidelines; and overall morbidity was assessed using the Clavien–Dindo classification. Major complications were defined as Clavien–Dindo grade III or higher. Data collection Clinical data were collected from a prospectively maintained institutional database and electronic medical records. Variables included patient demographics, comorbidities, laboratory parameters, operative details, postoperative complications, duration of hospitalization, reinterventions, readmissions, 30-day mortality, and histopathological findings. Statistical analysis Statistical analysis was performed using SPSS version 28.0 (IBM Corp., Armonk, NY). Continuous variables were summarized as mean ± standard deviation or median with interquartile range, as appropriate, and compared using parametric or non-parametric tests based on distribution. Categorical variables were expressed as frequencies and percentages and compared using chi-square or Fisher’s exact tests. Univariate logistic regression analysis was performed to identify factors associated with CR-POPF. A two-sided p-value of < 0.05 was considered statistically significant. Results Patient characteristics The study enrolled 20 consecutive patients who underwent PRPD with ALD. The patients had a mean age of 57.30 ± 11.00 years and a median age of 59 years, with females comprising 55% of the group. The average body mass index (BMI) was 23.19 ± 2.34 kg/m 2 . The most frequently reported initial symptoms were jaundice (95%, n = 19) and pain in abdomen (85%, n = 17). Comorbidities included diabetes (25%, n = 5), and hypertension (25%, n = 5). Additionally, 90.0% (n = 18) had undergone preoperative biliary stenting. The mean hemoglobin was 11.27 ± 1.40 g/dL, and mean total bilirubin was 2.28 ± 3.72 mg/dL. The mean operative time was 403.5 ± 31.16 minutes, and the average intraoperative blood loss was 312.5 ± 79.26 mL; 25% (n = 5) received one unit of intraoperative transfusion. Intraoperatively, the pancreatic texture was described as soft in 8 patients (40.0%), and firm in 12 patients (60%), while the pancreatic duct diameter averaged 4.5 ± 2.06 mm. Table 1 . Table 1 Baseline Demography and Clinical Characteristics Characteristic ALD Group Non-ALD Group p-Value Age 57.30 ± 11.00 52.33 ± 12.68 0.101 Female 11(55%) 21(35%) 0.120 Male 9(45%) 39(65%) 0.120 BMI 23.19 ± 2.34 23.55 ± 3.31 0.600 Jaundice 19 (95.0%) 37 (61.7%) 0.004 Pain in abdomen 17 (85.0%) 26 (43.3%) 0.002 Pruritus 9 (45.0%) 13 (21.7%) 0.083 GI Bleed 0 (0.0%) 1 (1.7%) 1.000 Anorexia 9 (45.0%) 14 (23.3%) 0.117 Weight loss 2 (10.0%) 4 (6.7%) 0.637 Stented 18 (90.0%) 24 (40.0%) 0.001 DM 5 (25.0%) 19 (31.7%) 0.778 HTN 5 (25.0%) 7 (11.7%) 0.278 BA/COPD 0 (0.0%) 2 (3.3%) 1.000 Hemoglobin 11.27 ± 1.40 11.02 ± 1.75 0.523 Creatinine 0.79 ± 0.35 1.08 ± 0.27 0.003 Urea 20.16 ± 9.39 30.97 ± 7.15 < 0.001 Total Bilirubin 2.28 ± 3.72 6.06 ± 6.24 0.002 Direct Bilirubin 1.74 ± 3.08 5.00 ± 5.39 0.001 SGOT 72.30 ± 132.86 76.33 ± 42.86 0.895 SGPT 80.90 ± 140.30 75.88 ± 39.15 0.876 ALP 225.90 ± 197.13 455.92 ± 211.28 < 0.001 Albumin 3.66 ± 0.40 3.53 ± 0.60 0.277 PT 10.77 ± 0.90 11.00 ± 0.93 0.315 INR 1.01 ± 0.09 1.16 ± 0.15 3mm) 12/20 (60.0%) 37/60 (61.7%) 1.000 CCI Index 0.40 ± 0.60 0.42 ± 0.70 0.918 After matching, traditional POPF risk factors were broadly comparable: mean Fistula Risk Score (FRS) did not differ significantly between ALD and non-ALD groups, and the proportion of dilated ducts (> 3 mm) was similar (60.0% vs 61.7%; p ≈ 1.00) Comparative analysis Baseline characteristics were similar between the two groups. Preoperative biliary stenting was performed more frequently in the ALD group (90% vs. 40%, p = 0.001). Patients in the ALD group had a higher incidence of anorexia (45%) than those in the non-ALD group (23.3%) (p = 0.117), and weight loss was also more prevalent in the ALD group (10% vs. 6.7%, p = 0.637). The intraoperative data demonstrated that the mean operative time was 403.5 minutes in the ALD group compared to 396.88 ± 34.31 minutes in the non-ALD group, a difference that did not reach statistical significance. Likewise, estimated blood loss was similar between the two groups, with the ALD group averaging 312.5 ml and the non-ALD group averaging 450.16 ± 162.38 ml, suggesting that the inclusion of ALD did not influence surgical duration or blood loss. There was also no significant difference between groups in intraoperative blood transfusion rates. The pancreatic duct diameter tended to be smaller in the ALD group (4.5 ± 2.06 mm vs 5.3 ± 2.42 mm), although this did not reach statistical significance (p ≈ 0.16). The average duration of hospitalization following surgery was 12.2 ± 3.19 days. In the ALD cohort, periampullary malignancies predominated in 18/20 patients (90%), with the remainder comprising pancreatic head carcinoma in 1 (5%), and distal cholangiocarcinoma in 1 (5%). Histologically, adenocarcinoma was the dominant type in 19/20 patients (95%), with only 1 patient (5%) harboring benign pathology. In the non-ALD group, periampullary tumors accounted for 31/60 resections (52.5%), followed by distal cholangiocarcinoma in 9 (15.0%), pancreatic head tumors in 8 (13.3%), and benign periampullary or pancreatic lesions in 11 (18.3%). Overall, adenocarcinoma represented the commonest histologic type (45/60, 75.0%), with smaller numbers of IPMN (2/60, 3.3%), solid pseudopapillary tumor (1/60, 1.7%), and neuroendocrine carcinoma (1/60, 1.7%), while 11/60 (18.3%) resections yielded benign pathology. In the ALD group, 65.0% (13/20) developed biochemical leak, and 10% (2/20) developed CR-POPF (Grade B POPF n = 2, Grade C POPF n = 0), whereas in non-ALD group, 33.0% (n = 20/60) had biochemical leak, and 20% had CR-POPF (Grade B POPF n = 12, Grade C POPF n = 0). Table 2 . Table 2 POPF Grades POPF Grade ALD Group Non-ALD Group p-Value No POPF 5 (25.0%) 28 (46.7%) 0.149 CR-POPF POPF Grade B 2 (10.0%) 12 (20.0%) 0.499 POPF Grade C 0 (0.0%) 0 (0.0%) 1.000 Additional postoperative outcomes were thoroughly examined. The analysis revealed that no DGE was observed in the ALD group, whereas 10 (16.7%),17 (28.3%) and 1 (1.7%) patient in the non- ALD group experienced DGE Grade A, B and C respectively. SSIs occurred in 2 ALD patients (10%) and 15 non-ALD patients (25%), with no statistically significant difference between the groups. In the ALD group, there were no cases of PPH; the non-ALD group showed 3 cases (5%) of Grade B, and 1 case (1.7%) of Grade C PPH. There were no cases of bile leak in the ALD group vs 6 cases (10%) had bile leak in non-ALD group. Table 3 . Table 3 DGE, PPH, and Bile Leak Complication Grade ALD Group Non-ALD Group p-Value DGE No DGE 20 (100.0%) 32 (53.3%) < 0.001 DGE Grade A 0 (0.0%) 10 (16.7%) 0.059 DGE Grade B 0 (0.0%) 17 (28.3%) 0.005 DGE Grade C 0 (0.0%) 1 (1.7%) 1.000 Overall DGE 0 (0.0%) 28 (46.7%) < 0.001 PPH No PPH 20 (100.0%) 56 (93.3%) 0.567 PPH Grade A 0 (0.0%) 0 (0.0%) 1.000 PPH Grade B 0 (0.0%) 3 (5.0%) 0.569 PPH Grade C 0 (0.0%) 1 (1.7%) 1.000 Bile Leak No Bile Leak 20 (100.0%) 54 (90.0%) 0.328 Bile Leak 0 (0.0%) 6 (10.0%) 0.328 Other complications such as ascites, surgical site infection (SSI), urinary tract infection, ileus, and intestinal anastomosis leak did not differ significantly between the groups. The mean postoperative hospital stay was significantly shorter for the ALD group (12.2 days) compared to the non-ALD group (16.3 ± 6.67 days) (p < 0.001). Postoperative morbidity assessed using the Clavien–Dindo classification demonstrated a lower proportion of major complications (≥ Grade IIIa) in the ALD group (5%, n = 1/20) compared with the non-ALD group (15%, n = 9/60), although this difference did not reach statistical significance (p = 0.27). No patient in either cohort experienced Grade IV complications. There were no readmissions or 30-day mortality in either group. Table 4 – Global outcomes Outcome ALD Group Non-ALD Group p-Value CR-POPF (ISGPS Grade B/C) 2(10.0%) 12(20.0%) 0.499 Any DGE (ISGPS Grade A/B/C) 0(0.0%) 28(46.7%) < 0.001 PPH (ISGPS Grade A/B/C) 0(0.0%) 4(6.7%) 0.567 Bile Leak 0(0.0%) 6 (10.0%) 0.328 Surgical site infection 2(10.0%) 15(25.0%) 0.214 Length of hospital stay, days 12.2 ± 3.19 16.3 ± 6.67 0.001 Reoperation for complications 0(0.0%) 2(3.3%) 1.000 CCI Index (mean ± SD) 0.40 ± 0.60 0.42 ± 0.70 0.918 Using the original Callery Fistula Risk Score (FRS) (gland texture, pathology, duct diameter and intraoperative blood loss) there was no significant difference in mean FRS or FRS risk categories between ALD and non-ALD groups after matching ( Table 5 ) , suggesting broadly comparable intrinsic POPF risk profiles. Table 5 – FRS Table Parameter ALD Group Non-ALD Group p-Value FRS total score (mean ± SD) 3.0 ± 1.8 3.6 ± 1.6 0.146 Negligible risk (FRS 0) subgroup 0(0.0%) 1 (1.7%) 1.000 Low risk (FRS 1–2) 9 (45.0%) 16 (26.7%) 0.165 Moderate risk (FRS 3–6) 11 (55.0%) 41 (68.3%) 0.293 High risk (FRS 7–10) 0(0.0%) 2 (3.3%) 1.000 Univariate analysis Univariate analysis demonstrated that most blood parameters did not have a significant association with POPF. The exceptions were the tumor marker CA19-9 (p = 0.006), BMI (p = 0.02), and COPD/BA (p = 0.038) which showed a significant relationship with POPF. There were no significant associations identified between intraoperative predictors including pancreatic duct diameter, gland texture, intraoperative blood loss or transfusion, or the duration of surgery and POPF. Table 6 . Table 6 Univariate Logistic Regression: Predictors of CR‑POPF Predictor Estimate Z p-value Odds Ratio 95% CI Lower 95% CI Upper CA 19 − 9, log10(U/mL + 1) 1.901 2.753 0.006 6.694 1.73 25.911 BMI (kg/m²) 0.247 2.325 0.02 1.28 1.039 1.576 COPD/BA (Y) 3.281 2.077 0.038 26.6 1.203 588.082 Age (per year) 0.027 1.016 0.31 1.027 0.975 1.083 Male sex (vs female) -0.495 -0.836 0.403 0.61 0.191 1.945 Diabetes (Y) 0.318 0.512 0.608 1.374 0.407 4.637 Hypertension (Y) -0.069 -0.082 0.934 0.933 0.181 4.817 Abdominal pain (Y) -0.893 -1.462 0.144 0.409 0.124 1.355 Jaundice (Y) 0.537 0.764 0.445 1.711 0.431 6.786 Pruritus (Y) 0.065 0.099 0.921 1.067 0.297 3.836 GI bleeding (Y) 0.409 0.247 0.805 1.506 0.058 38.866 Anorexia (Y) -0.011 -0.016 0.987 0.989 0.276 3.545 Weight loss (Y) -0.064 -0.056 0.955 0.938 0.101 8.719 Preoperative stenting (Y) 0.227 0.383 0.702 1.255 0.392 4.017 Hemoglobin (g/dL) -0.201 -1.112 0.266 0.818 0.574 1.166 Total bilirubin (mg/dL) -0.001 -0.018 0.985 0.999 0.906 1.102 Direct bilirubin (mg/dL) 0.006 0.104 0.917 1.006 0.899 1.126 SGOT (U/L) -0.005 -0.702 0.483 0.995 0.981 1.009 SGPT (U/L) -0.004 -0.593 0.553 0.996 0.983 1.009 ALP (U/L) 0.002 1.295 0.195 1.002 0.999 1.004 Albumin (g/dL) -0.426 -0.778 0.437 0.653 0.223 1.912 PT (s) -0.305 -0.898 0.369 0.737 0.379 1.435 INR 0.066 0.034 0.973 1.068 0.025 45.143 Urea (mg/dL) 0.023 0.689 0.491 1.023 0.959 1.091 Creatinine (mg/dL) 0.424 0.461 0.645 1.528 0.252 9.256 Soft gland (vs hard) -0.693 -1.143 0.253 0.5 0.152 1.642 PD diameter (mm) 0.072 0.578 0.564 1.075 0.842 1.373 PD dilated (Y) -0.207 -0.347 0.729 0.813 0.252 2.618 OT Duration 0.135 0.542 0.588 1.145 0.701 1.869 Blood loss (per 100 mL) 0.087 0.487 0.627 1.091 0.767 1.552 Discussion Pancreaticoduodenectomy remains the cornerstone surgical treatment for periampullary, distal bile duct, and pancreatic head malignancies. While operative mortality has declined substantially with increasing surgical specialization, postoperative morbidity continues to represent a major clinical challenge. Among these complications, CR-POPF and DGE are particularly impactful, as they prolong hospitalization, delay adjuvant therapy, and increase healthcare utilization. The pathophysiology of CR-POPF is multifactorial and extends beyond gland- and duct- related factors alone. Mechanical and functional factors within the reconstructed jejunal limb may increase intraluminal pressure across the PJ and HJ. 14 Such pressure elevations may exacerbate anastomotic stress and contribute to leakage, secondary infection, and delayed recovery. In this context, ALD may facilitate early decompression of the afferent limb, thereby improving drainage of secretions during the critical initial postoperative phase. Another factor implicated is infected bile and possibility of pancreatic enzyme activation contributing to development of post operative pancreatitis and CR-POPF. 15 Prior studies evaluating jejunal or biliary decompression following PD have reported heterogeneous outcomes with respect to pancreatic fistula and gastric emptying. In a study by Yin et al., which used continuous negative suction with ALD tube modification (added extra holes in gastric part of the tube) showed a statistically significant difference in incidence of POPF 23.4% vs 39.4% (p = 0.018) in ALD and non-ALD groups respectively. Contrary to POPF, incidence of DGE was more in ALD group compared to non-ALD group, though it didn’t reach statistical significance (28.7% vs 20.2%, p = 0.175). 12 Unlike reconstructive strategies that introduce additional anastomoses, ALD functions as a temporary physiological adjunct aimed at reducing luminal pressure without altering gastrointestinal continuity. This distinction is clinically relevant, as additional anastomoses may themselves introduce new risks. The marked reduction in DGE observed in the ALD group in the present study supports the hypothesis that early afferent limb decompression may favorably influence gastric emptying by limiting jejunal distension and edema at the GJ. 16,17 Our findings differ in that ALD showed a marked reduction in DGE and length of hospital stay (p < 0.001). Since both cohorts followed identical postoperative feeding protocols the observed difference in DGE is unlikely to be attributable to variations in postoperative care. Although the reduction in CR-POPF did not reach statistical significance, the numerical difference favors ALD and suggests a potential protective effect that warrants further evaluation in larger cohorts. (10% vs 20%, p = 0.499), this analysis was clearly underpowered for this endpoint. Only fourteen CR-POPF events occurred in the entire matched cohort, limiting the ability to detect moderate effect sizes. Importantly, the directionality of effect observed in this study aligns with the proposed physiological rationale of ALD and should be interpreted as hypothesis generating rather than confirmatory. 14 , 15 Univariate analysis identified elevated CA19-9 levels, higher body mass index, and the presence of chronic obstructive pulmonary disease or bronchial asthma as factors associated with increased odds of CR-POPF. These findings highlight the contribution of systemic disease burden and metabolic factors to fistula risk, beyond local pancreatic characteristics alone. Given the limited number of CR-POPF events, multivariable modeling was not pursued to avoid overfitting. Limitations Small sample size with 1:3 propensity matched controls; the hybrid design using a prospectively collected intervention cohort and retrospectively accrued historical controls; and residual confounding despite propensity matching. Several preoperative variables (e.g. jaundice, stenting, bilirubin and ALP) remained imbalanced after matching, and perioperative care protocols may have evolved over the 4-year historical control period, introducing temporal bias. In addition, because only two CR-POPF events occurred in the ALD arm, multivariable regression would violate conventional events per predictor rules and we therefore restricted our analysis to univariate exploratory signals. Conclusion This single-centre study evaluated ALD as a simple intraoperative adjunct during PD using a hybrid cohort design with propensity score matching. ALD was safe and feasible and was associated with a significant reduction in DGE and a shorter postoperative hospital stay in this matched cohort. Although a numerically lower rate of CR-POPF was observed in the ALD group, this difference did not reach statistical significance in the present analysis. Given the limited sample size and low number of fistula events, these findings should be interpreted as exploratory. Larger prospective, multicentre studies are required to confirm these findings and to more clearly define the role of ALD in reducing postoperative morbidity after PD. Abbreviations CR POPF-Clinically relevant postoperative pancreatic fistula PD Pancreaticoduodenectomy ALD Afferent loop decompression PRPD Pylorus Resecting pancreaticoduodenectomy DGE Delayed gastric emptying PPH Post‑pancreatectomy hemorrhage PJ Pancreaticojejunostomy HJ Hepaticojejunostomy GJ Gastrojejunostomy FJ Feeding Jejunostomy ISGPS International Study Group of Pancreatic Surgery SDs Standard deviations CTRI Clinical Trial Registry India ALP Alkaline Phosphatase FRS Fistula Risk Score SMD Standardized Mean Difference ISGLS International Study Group of Liver Surgery LOS Length of stay CCI Charlson Comorbidity Index SSI Surgical site infection Declarations Clinical trial number: This study was retrospectively registered with the Clinical Trial Registry of India (CTRI), Registration number CTRI/2025/12/098589. Ethics approval and consent to participate: This study was approved by the Institutional ethics committee, Institute of Medical Science (IMS) and SUM Hospital. IEC Registration No: ECR/627/Inst/OR/2014/RR-20. Written informed consent was obtained from all participants prior to inclusion in the study. The study followed the Declaration of Helsinki. Consent to participate: Written informed consent was obtained from all participants prior to inclusion in the study. Consent for publication: Written informed consent was obtained from all participants for publication of the study and accompanying images. Funding: No funding was obtained for the study Availability of data and material: The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality restrictions but are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Authors Contributions: D.P and J.J wrote the main manuscript text and performed manuscript drafting. D.P collected clinical data and performed statistical analysis. S.S.M and P.B prepared the figures and tables. R.R.M and S.R.H critically revised manuscript for important intellectual content. All authors reviewed and approved the final manuscript. Corresponding author: Dr. Dipen Patel. Email - [email protected] ORCID Dipen Patel - https://orcid.org/0009-0001-7436-518X Jyotirmay Jena - https://orcid.org/0000-0002-2986-078X, Sumit Subhadarshi Mohanty - https://orcid.org/0000-0003-3252-8662, Pratik Bhagat - https://orcid.org/0009-0001-4753-2085 Raghunath Raja Marimuthu - https://orcid.org/0000-0001-9435-4042 Swamy Rajesh Hudugur - https://orcid.org/0009-0007-4564-0211 References Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015;220(4):530–6. 10.1016/j.jamcollsurg.2014.12.031 . Epub 2015 Jan 6. PMID: 25724606. Mikulić D, Bubalo T, Mrzljak A, Škrtić A, Jadrijević S, Kanižaj TF, Kocman B. Role of total pancreatectomy in the treatment of paraduodenal pancreatitis: A case report. 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Effect of jejunal and biliary decompression on postoperative complications and pancreatic leakage arising from pancreatojejunostomy after pancreatoduodenectomy. World J Surg. 2006;30(11):1985–9. 10.1007/s00268-005-0475-1 . Available from: https://link.springer.com/article/10.1007/s00268-005-0475-1 Muscarella P. Invited commentary on Effect of jejunal and biliary decompression on postoperative complications and pancreatic leakage after pancreatoduodenectomy. World J Surg. 2006;30(11):1990–1. 10.1007/s00268-006-0421-x . Available from: https://link.springer.com/article/10.1007/s00268-006-0421-x Kukita K, Ishikawa O, Yamaue H, Hijioka S, Takahashi H, Ohtsuka M et al. Preventive effect of jejunal limb decompression on early-onset postoperative cholangitis after pancreaticoduodenectomy: a propensity score–matched study. J Gastrointest Surg. 2025; (Epub ahead of print). 10.1007/s11605-025-05555-3 . Available from: https://pubmed.ncbi.nlm.nih.gov/40617265 Yin J, Lu Z, Wu P, Wu J, Gao W, Wei J, Guo F, Chen J, Jiang K, Miao Y. Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy. World J Surg. 2018;42(11):3726–3735. 10.1007/s00268-018-4679-6 . PMID: 29968100. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CM, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584–591. doi: 10.1016/j.surg.2016.11.014. Epub 2016 Dec 28. Erratum in: Surgery. 2024 Sep;176(3):988–989. 10.1016/j.surg.2024.05.043 . PMID: 28040257. Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions? World J Gastrointest Surg. 2015;7(9):190–5. 10.4240/wjgs.v7.i9.190 . PMID: 26425267; PMCID: PMC4582236. Okano K, Suzuki Y. Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage. World J Gastroenterol. 2019;25(47):6847–56. 10.3748/wjg.v25.i47.6847 . PMID: 31885425; PMCID: PMC6931003. 1, Cordesmeyer S, Lodde S, Zeden K, et al. Prevention of Delayed Gastric Emptying After Pylorus-Preserving Pancreatoduodenectomy with Antecolic Reconstruction, a Long Jejunal Loop, and a Jejuno-Jejunostomy. J Gastrointest Surg. 2014;18:662–73. https://doi.org/10.1007/s11605-013-2446-4 . 2, Xu B, Zhu YH, Qian MP, Shen RR, Zheng WY, Zhang YW. Braun Enteroenterostomy Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015;94(32):e1254. doi: 10.1097/MD.0000000000001254. Erratum in: Medicine (Baltimore). 2015;94(37):1. Erratum in: Medicine (Baltimore). 2016;95(24):e2208. 10.1097/01.md.0000484784.15522.08 . PMID: 26266356; PMCID: PMC4616697. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-8354959","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":571622184,"identity":"4163dfa6-face-4b90-999c-ddfd1ea806aa","order_by":0,"name":"Dipen 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1","display":"","copyAsset":false,"role":"figure","size":244819,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow diagram of the prospective ALD cohort.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8354959/v1/6d4eb4e252dda2c97560cf45.jpeg"},{"id":100126582,"identity":"9ba54291-5aa5-4b43-87aa-cfc8474b6cd4","added_by":"auto","created_at":"2026-01-13 09:25:14","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":220904,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow diagram of the retrospective non-ALD control cohort.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8354959/v1/3b792344e60fccf72d65b9bc.jpeg"},{"id":100367547,"identity":"e2612b9d-906c-4e25-be61-eb252d7336ef","added_by":"auto","created_at":"2026-01-16 07:57:07","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":979794,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration (Left) and operative image of Afferent Loop Decompression (Right) with intraoperative guiding of Ryle’s tube after completion of posterior layer of GJ. (Middle)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8354959/v1/11384513dbd107e7ed89cf9d.jpeg"},{"id":100546225,"identity":"28993be6-2f61-4dc8-af95-fdfdc2884d89","added_by":"auto","created_at":"2026-01-19 08:02:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2443434,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8354959/v1/68754999-4550-480f-8b1f-98577c6ae61b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Afferent Loop Decompression and Outcomes After Pancreaticoduodenectomy: Hybrid Cohort with Propensity Score Matching","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePancreaticoduodenectomy (PD) remains the definitive surgical intervention for periampullary malignancies and selected benign conditions involving pancreatic head and distal bile duct.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Despite substantial reductions in operative mortality with increasing surgical centralization and perioperative optimization, PD continues to be associated with a high burden of postoperative morbidity, reported in up to one-third to one-half of patients even in specialized centers.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAmong postoperative complications, clinically relevant postoperative pancreatic fistula (CR-POPF) represents a major determinant of adverse outcomes following PD.\u003csup\u003e5\u003c/sup\u003e The risk of CR-POPF is influenced by a combination of patient-related, gland-related, and operative factors, including pancreatic texture, duct diameter, intraoperative blood loss, preoperative biliary stenting, nutritional status and systemic comorbidities.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Although multiple technical modifications and adjunctive measures have been proposed to mitigate fistula formation - such as variations in pancreatoenteric anastomosis, pharmacological suppression of pancreatic secretion, and drain management strategies - no single intervention has demonstrated consistent benefit across diverse risk profiles.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAn often-underrecognized contributor to early postoperative morbidity after PD is altered physiology within the reconstructed jejunal limb. Postoperative edema, ileus, or kinking of the afferent limb may impair effective drainage of pancreatic and biliary secretions, resulting in elevated intraluminal pressure across the pancreatojejunostomy (PJ) and hepaticojejunostomy (HJ). This mechanical stress, particularly in the early postoperative period, may predispose to anastomotic leakage and exacerbate downstream complications such as delayed gastric emptying (DGE) and postoperative cholangitis.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAfferent loop decompression (ALD) has been proposed as a simple intraoperative strategy to facilitate early postoperative drainage of biliopancreatic secretions by providing controlled decompression of the afferent jejunal limb. Unlike reconstructive modifications that introduce additional anastomoses, ALD aims to reduce intraluminal pressure without altering gastrointestinal continuity. Previous reports evaluating jejunal or biliary decompression techniques after PD have been limited by heterogeneous methodologies, small sample sizes, and non-randomized designs, with variable effects reported on pancreatic fistula and gastric emptying outcomes.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the continued uncertainty surrounding the role of decompressive strategies in reducing PD-related morbidity, further evaluation of ALD in contemporary surgical practice is warranted. Using a hybrid cohort design with prospective enrollment of ALD cases and propensity score matched historical controls, we aimed to examine the association of ALD with CR-POPF, DGE, post-pancreatectomy hemorrhage (PPH), bile leak, and length of hospital stay.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis study was conducted at a tertiary care hepatopancreatobiliary (HPB) referral centre in eastern India. A hybrid cohort design was employed, comprising a prospectively enrolled intervention group undergoing ALD during pylorus resecting pancreaticoduodenectomy (PRPD) and a retrospectively identified control group of patients who underwent PRPD without ALD at the same institution.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eAdult patients (\u0026ge;\u0026thinsp;18 years) undergoing PRPD were eligible for inclusion. The prospective ALD cohort consisted of consecutive patients operated between August 2024 and July 2025. The control cohort was derived from patients who underwent PRPD without ALD during the four years preceding the study period.\u003c/p\u003e \u003cp\u003ePatients who had accidental removal of the decompression tube in the postoperative period were excluded. None of the patients in either cohort received neoadjuvant chemotherapy or chemoradiotherapy. The Study flow diagrams for both cohorts are depicted in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e \u003cb\u003eand trial registration\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e The study protocol was approved by the Institutional Ethics Committee of the Institute of Medical Sciences and SUM Hospital (IEC Registration No: ECR/627/Inst/OR/2014/RR-20). Written informed consent was obtained from all prospectively enrolled participants. The study was registered with the Clinical Trial Registry of India (CTRI/2025/12/098589) and was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003ch3\u003eSurgical technique and afferent loop decompression\u003c/h3\u003e\n\u003cp\u003eAll patients underwent open PRPD performed by one of two senior HPB surgeons with extensive experience in pancreatic surgery. Reconstruction was standardized across both cohorts and consisted of PJ (modified Blumgart technique), HJ, antecolic gastrojejunostomy (GJ), and feeding jejunostomy (FJ) (Witzel technique).\u003c/p\u003e \u003cp\u003eIn the ALD group, afferent loop decompression was achieved intraoperatively by advancing a 16-Fr Ryle\u0026rsquo;s tube into the afferent jejunal limb to a position within approximately 5 cm distal to the HJ, following completion of the posterior layer of the GJ. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) The tube was allowed to drain freely postoperatively and was typically removed on postoperative day five, unless DGE necessitated prolonged decompression. In the control group, a 16-Fr Ryle\u0026rsquo;s tube was positioned in the stomach as per standard practice.\u003c/p\u003e \u003cp\u003ePostoperative feeding protocols were uniform across both cohorts. Oral clear liquids were initiated from postoperative day four in the absence of DGE, with FJ support used as required.\u003c/p\u003e\n\u003ch3\u003ePropensity score matching\u003c/h3\u003e\n\u003cp\u003eTo minimize selection bias, patients in the ALD cohort were matched in a 1:3 ratio with controls using nearest neighbour propensity score matching without replacement. Matching variables included age, sex, preoperative biliary drainage, pancreatic duct diameter, pancreatic texture, and intraoperative blood loss. Standardized mean differences were assessed to evaluate adequacy of matching.\u003c/p\u003e \u003cp\u003eThe Fistula Risk Score (FRS) was calculated for all patients using pancreatic texture, duct diameter, pathology, and intraoperative blood loss.\u003c/p\u003e\n\u003ch3\u003eOutcomes and definitions\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the incidence of CR-POPF, defined as ISGPS grade B or C fistula. Secondary outcomes included DGE, post-pancreatectomy haemorrhage (PPH), bile leak, postoperative morbidity, and length of hospital stay.\u003c/p\u003e \u003cp\u003ePostoperative complications were classified according to established international definitions: CR-POPF, DGE, and PPH were graded using ISGPS criteria\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e; bile leak was defined according to ISGLS guidelines; and overall morbidity was assessed using the Clavien\u0026ndash;Dindo classification. Major complications were defined as Clavien\u0026ndash;Dindo grade III or higher.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eClinical data were collected from a prospectively maintained institutional database and electronic medical records. Variables included patient demographics, comorbidities, laboratory parameters, operative details, postoperative complications, duration of hospitalization, reinterventions, readmissions, 30-day mortality, and histopathological findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS version 28.0 (IBM Corp., Armonk, NY). Continuous variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with interquartile range, as appropriate, and compared using parametric or non-parametric tests based on distribution. Categorical variables were expressed as frequencies and percentages and compared using chi-square or Fisher\u0026rsquo;s exact tests.\u003c/p\u003e \u003cp\u003eUnivariate logistic regression analysis was performed to identify factors associated with CR-POPF. A two-sided p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe study enrolled 20 consecutive patients who underwent PRPD with ALD. The patients had a mean age of 57.30\u0026thinsp;\u0026plusmn;\u0026thinsp;11.00 years and a median age of 59 years, with females comprising 55% of the\u003c/p\u003e \u003cp\u003egroup. The average body mass index (BMI) was 23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 kg/m\u003csup\u003e2\u003c/sup\u003e. The most frequently reported initial symptoms were jaundice (95%, n\u0026thinsp;=\u0026thinsp;19) and pain in abdomen (85%, n\u0026thinsp;=\u0026thinsp;17). Comorbidities included diabetes (25%, n\u0026thinsp;=\u0026thinsp;5), and hypertension (25%, n\u0026thinsp;=\u0026thinsp;5).\u003c/p\u003e \u003cp\u003eAdditionally, 90.0% (n\u0026thinsp;=\u0026thinsp;18) had undergone preoperative biliary stenting. The mean hemoglobin was 11.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40 g/dL, and mean total bilirubin was 2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.72 mg/dL. The mean operative time was 403.5\u0026thinsp;\u0026plusmn;\u0026thinsp;31.16 minutes, and the average intraoperative blood loss was 312.5\u0026thinsp;\u0026plusmn;\u0026thinsp;79.26 mL; 25% (n\u0026thinsp;=\u0026thinsp;5) received one unit of intraoperative transfusion. Intraoperatively, the pancreatic texture was described as soft in 8 patients (40.0%), and firm in 12 patients (60%), while the pancreatic duct diameter averaged 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 mm. 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\u003eBaseline Demography and Clinical Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.30\u0026thinsp;\u0026plusmn;\u0026thinsp;11.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.33\u0026thinsp;\u0026plusmn;\u0026thinsp;12.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (95.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (61.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain in abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (85.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePruritus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGI Bleed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBA/COPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.16\u0026thinsp;\u0026plusmn;\u0026thinsp;9.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.97\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect Bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGOT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.30\u0026thinsp;\u0026plusmn;\u0026thinsp;132.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.33\u0026thinsp;\u0026plusmn;\u0026thinsp;42.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.90\u0026thinsp;\u0026plusmn;\u0026thinsp;140.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.88\u0026thinsp;\u0026plusmn;\u0026thinsp;39.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e225.90\u0026thinsp;\u0026plusmn;\u0026thinsp;197.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e455.92\u0026thinsp;\u0026plusmn;\u0026thinsp;211.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatic duct diameter in mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD dilated (\u0026gt;\u0026thinsp;3mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/20 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37/60 (61.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter matching, traditional POPF risk factors were broadly comparable: mean Fistula Risk Score (FRS) did not differ significantly between ALD and non-ALD groups, and the proportion of dilated ducts (\u0026gt;\u0026thinsp;3 mm) was similar (60.0% vs 61.7%; p\u0026thinsp;\u0026asymp;\u0026thinsp;1.00)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComparative analysis\u003c/h2\u003e \u003cp\u003eBaseline characteristics were similar between the two groups. Preoperative biliary stenting was performed more frequently in the ALD group (90% vs. 40%, p\u0026thinsp;=\u0026thinsp;0.001). Patients in the ALD group had a higher incidence of anorexia (45%) than those in the non-ALD group (23.3%) (p\u0026thinsp;=\u0026thinsp;0.117), and weight loss was also more prevalent in the ALD group (10% vs. 6.7%, p\u0026thinsp;=\u0026thinsp;0.637).\u003c/p\u003e \u003cp\u003eThe intraoperative data demonstrated that the mean operative time was 403.5 minutes in the ALD group compared to 396.88\u0026thinsp;\u0026plusmn;\u0026thinsp;34.31 minutes in the non-ALD group, a difference that did not reach statistical significance. Likewise, estimated blood loss was similar between the two groups, with the ALD group averaging 312.5 ml and the non-ALD group averaging 450.16\u0026thinsp;\u0026plusmn;\u0026thinsp;162.38 ml, suggesting that the inclusion of ALD did not influence surgical duration or blood loss. There was also no significant difference between groups in intraoperative blood transfusion rates. The pancreatic duct diameter tended to be smaller in the ALD group (4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 mm vs 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42 mm), although this did not reach statistical significance (p\u0026thinsp;\u0026asymp;\u0026thinsp;0.16). The average duration of hospitalization following surgery was 12.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19 days.\u003c/p\u003e \u003cp\u003eIn the ALD cohort, periampullary malignancies predominated in 18/20 patients (90%), with the remainder comprising pancreatic head carcinoma in 1 (5%), and distal cholangiocarcinoma in 1 (5%). Histologically, adenocarcinoma was the dominant type in 19/20 patients (95%), with only 1 patient (5%) harboring benign pathology. In the non-ALD group, periampullary tumors accounted for 31/60 resections (52.5%), followed by distal cholangiocarcinoma in 9 (15.0%), pancreatic head tumors in 8 (13.3%), and benign periampullary or pancreatic lesions in 11 (18.3%). Overall, adenocarcinoma represented the commonest histologic type (45/60, 75.0%), with smaller numbers of IPMN (2/60, 3.3%), solid pseudopapillary tumor (1/60, 1.7%), and neuroendocrine carcinoma (1/60, 1.7%), while 11/60 (18.3%) resections yielded benign pathology.\u003c/p\u003e \u003cp\u003eIn the ALD group, 65.0% (13/20) developed biochemical leak, and 10% (2/20) developed CR-POPF (Grade B POPF n\u0026thinsp;=\u0026thinsp;2, Grade C POPF n\u0026thinsp;=\u0026thinsp;0), whereas in non-ALD group, 33.0% (n\u0026thinsp;=\u0026thinsp;20/60) had biochemical leak, and 20% had CR-POPF (Grade B POPF n\u0026thinsp;=\u0026thinsp;12, Grade C POPF n\u0026thinsp;=\u0026thinsp;0). 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\u003ePOPF Grades\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOPF Grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo POPF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eCR-POPF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOPF Grade B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOPF Grade C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditional postoperative outcomes were thoroughly examined. The analysis revealed that no DGE was observed in the ALD group, whereas 10 (16.7%),17 (28.3%) and 1 (1.7%) patient in the non- ALD group experienced DGE Grade A, B and C respectively. SSIs occurred in 2 ALD patients (10%) and 15 non-ALD patients (25%), with no statistically significant difference between the groups. In the ALD group, there were no cases of PPH; the non-ALD group showed 3 cases (5%) of Grade B, and 1 case (1.7%) of Grade C PPH. There were no cases of bile leak in the ALD group vs 6 cases (10%) had bile leak in non-ALD group. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\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\u003eDGE, PPH, and Bile Leak\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-ALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eDGE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo DGE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDGE Grade A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDGE Grade B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDGE Grade C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall DGE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo PPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (93.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPH Grade A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPH Grade B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPH Grade C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBile Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Bile Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBile Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOther complications such as ascites, surgical site infection (SSI), urinary tract infection, ileus, and intestinal anastomosis leak did not differ significantly between the groups. The mean postoperative hospital stay was significantly shorter for the ALD group (12.2 days) compared to the non-ALD group (16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.67 days) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003ePostoperative morbidity assessed using the Clavien\u0026ndash;Dindo classification demonstrated a lower proportion of major complications (\u0026ge;\u0026thinsp;Grade IIIa) in the ALD group (5%, n\u0026thinsp;=\u0026thinsp;1/20) compared with the non-ALD group (15%, n\u0026thinsp;=\u0026thinsp;9/60), although this difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.27). No patient in either cohort experienced Grade IV complications. There were no readmissions or 30-day mortality in either group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Global outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR-POPF (ISGPS Grade B/C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny DGE (ISGPS Grade A/B/C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPH (ISGPS Grade A/B/C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4(6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15(25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation for complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI Index (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUsing the original Callery Fistula Risk Score (FRS) (gland texture, pathology, duct diameter and intraoperative blood loss) there was no significant difference in mean FRS or FRS risk categories between ALD and non-ALD groups after matching \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, suggesting broadly comparable intrinsic POPF risk profiles.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; FRS Table\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ALD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFRS total score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegligible risk (FRS 0) subgroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow risk (FRS 1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate risk (FRS 3\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (55.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (68.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh risk (FRS 7\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eUnivariate analysis\u003c/h2\u003e \u003cp\u003eUnivariate analysis demonstrated that most blood parameters did not have a significant association with POPF. The exceptions were the tumor marker CA19-9 (p\u0026thinsp;=\u0026thinsp;0.006), BMI (p\u0026thinsp;=\u0026thinsp;0.02), and COPD/BA (p\u0026thinsp;=\u0026thinsp;0.038) which showed a significant relationship with POPF. There were no significant associations identified between intraoperative predictors including pancreatic duct diameter, gland texture, intraoperative blood loss or transfusion, or the duration of surgery and POPF. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate Logistic Regression: Predictors of CR‑POPF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI Lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI Upper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA 19\u0026thinsp;\u0026minus;\u0026thinsp;9, log10(U/mL\u0026thinsp;+\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.911\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD/BA (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e588.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (per year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex (vs female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.945\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.355\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJaundice (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.786\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePruritus (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGI bleeding (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e38.866\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight loss (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative stenting (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect bilirubin (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGOT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGPT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e45.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft gland (vs hard)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD diameter (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD dilated (Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.618\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOT Duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.869\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (per 100 mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.552\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePancreaticoduodenectomy remains the cornerstone surgical treatment for periampullary, distal bile duct, and pancreatic head malignancies. While operative mortality has declined substantially with increasing surgical specialization, postoperative morbidity continues to represent a major clinical challenge. Among these complications, CR-POPF and DGE are particularly impactful, as they prolong hospitalization, delay adjuvant therapy, and increase healthcare utilization.\u003c/p\u003e \u003cp\u003eThe pathophysiology of CR-POPF is multifactorial and extends beyond gland- and duct- related factors alone. Mechanical and functional factors within the reconstructed jejunal limb may increase intraluminal pressure across the PJ and HJ.\u003csup\u003e14\u003c/sup\u003e Such pressure elevations may exacerbate anastomotic stress and contribute to leakage, secondary infection, and delayed recovery.\u003c/p\u003e \u003cp\u003eIn this context, ALD may facilitate early decompression of the afferent limb, thereby improving drainage of secretions during the critical initial postoperative phase. Another factor implicated is infected bile and possibility of pancreatic enzyme activation contributing to development of post operative pancreatitis and CR-POPF.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrior studies evaluating jejunal or biliary decompression following PD have reported heterogeneous outcomes with respect to pancreatic fistula and gastric emptying. In a study by Yin et al., which used continuous negative suction with ALD tube modification (added extra holes in gastric part of the tube) showed a statistically significant difference in incidence of POPF 23.4% vs 39.4% (p\u0026thinsp;=\u0026thinsp;0.018) in ALD and non-ALD groups respectively. Contrary to POPF, incidence of DGE was more in ALD group compared to non-ALD group, though it didn\u0026rsquo;t reach statistical significance (28.7% vs 20.2%, p\u0026thinsp;=\u0026thinsp;0.175).\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnlike reconstructive strategies that introduce additional anastomoses, ALD functions as a temporary physiological adjunct aimed at reducing luminal pressure without altering gastrointestinal continuity. This distinction is clinically relevant, as additional anastomoses may themselves introduce new risks. The marked reduction in DGE observed in the ALD group in the present study supports the hypothesis that early afferent limb decompression may favorably influence gastric emptying by limiting jejunal distension and edema at the GJ. \u003csup\u003e16,17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur findings differ in that ALD showed a marked reduction in DGE and length of hospital stay (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Since both cohorts followed identical postoperative feeding protocols the observed difference in DGE is unlikely to be attributable to variations in postoperative care. Although the reduction in CR-POPF did not reach statistical significance, the numerical difference favors ALD and suggests a potential protective effect that warrants further evaluation in larger cohorts. (10% vs 20%, p\u0026thinsp;=\u0026thinsp;0.499), this analysis was clearly underpowered for this endpoint. Only fourteen CR-POPF events occurred in the entire matched cohort, limiting the ability to detect moderate effect sizes. Importantly, the directionality of effect observed in this study aligns with the proposed physiological rationale of ALD and should be interpreted as hypothesis generating rather than confirmatory.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnivariate analysis identified elevated CA19-9 levels, higher body mass index, and the presence of chronic obstructive pulmonary disease or bronchial asthma as factors associated with increased odds of CR-POPF. These findings highlight the contribution of systemic disease burden and metabolic factors to fistula risk, beyond local pancreatic characteristics alone. Given the limited number of CR-POPF events, multivariable modeling was not pursued to avoid overfitting.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSmall sample size with 1:3 propensity matched controls; the hybrid design using a prospectively collected intervention cohort and retrospectively accrued historical controls; and residual confounding despite propensity matching. Several preoperative variables (e.g. jaundice, stenting, bilirubin and ALP) remained imbalanced after matching, and perioperative care protocols may have evolved over the 4-year historical control period, introducing temporal bias. In addition, because only two CR-POPF events occurred in the ALD arm, multivariable regression would violate conventional events per predictor rules and we therefore restricted our analysis to univariate exploratory signals.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis single-centre study evaluated ALD as a simple intraoperative adjunct during PD using a hybrid cohort design with propensity score matching. ALD was safe and feasible and was associated with a significant reduction in DGE and a shorter postoperative hospital stay in this matched cohort. Although a numerically lower rate of CR-POPF was observed in the ALD group, this difference did not reach statistical significance in the present analysis.\u003c/p\u003e \u003cp\u003eGiven the limited sample size and low number of fistula events, these findings should be interpreted as exploratory. Larger prospective, multicentre studies are required to confirm these findings and to more clearly define the role of ALD in reducing postoperative morbidity after PD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePOPF-Clinically relevant postoperative pancreatic fistula\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAfferent loop decompression\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePylorus Resecting pancreaticoduodenectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDGE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDelayed gastric emptying\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost‑pancreatectomy hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePancreaticojejunostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepaticojejunostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGastrojejunostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFeeding Jejunostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISGPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Study Group of Pancreatic Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Trial Registry India\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlkaline Phosphatase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFistula Risk Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandardized Mean Difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISGLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Study Group of Liver Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLength of stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCharlson Comorbidity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number:\u0026nbsp;This study was retrospectively registered with the Clinical Trial Registry of India (CTRI), Registration number CTRI/2025/12/098589.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: This study was approved by the Institutional ethics committee, Institute of Medical Science (IMS) and SUM Hospital. IEC Registration No: ECR/627/Inst/OR/2014/RR-20. Written informed consent was obtained from all participants prior to inclusion in the study. The study followed the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent to participate: Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Written informed consent was obtained from all participants for publication of the study and accompanying images.\u003c/p\u003e\n\u003cp\u003eFunding: No funding was obtained for the study\u003c/p\u003e\n\u003cp\u003eAvailability of data and material: The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eAuthors Contributions: D.P and J.J wrote the main manuscript text and performed manuscript drafting. D.P collected clinical data and performed statistical analysis. S.S.M and P.B prepared the figures and tables. R.R.M and S.R.H critically revised manuscript for important intellectual content. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCorresponding author: Dr. Dipen Patel. Email - [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDipen Patel - https://orcid.org/0009-0001-7436-518X\u003c/p\u003e\n\u003cp\u003eJyotirmay Jena - https://orcid.org/0000-0002-2986-078X,\u003c/p\u003e\n\u003cp\u003eSumit Subhadarshi Mohanty - https://orcid.org/0000-0003-3252-8662,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePratik Bhagat - https://orcid.org/0009-0001-4753-2085\u003c/p\u003e\n\u003cp\u003eRaghunath Raja Marimuthu - https://orcid.org/0000-0001-9435-4042\u003c/p\u003e\n\u003cp\u003eSwamy Rajesh Hudugur - https://orcid.org/0009-0007-4564-0211\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. 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Erratum in: Medicine (Baltimore). 2016;95(24):e2208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.md.0000484784.15522.08\u003c/span\u003e\u003cspan address=\"10.1097/01.md.0000484784.15522.08\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 26266356; PMCID: PMC4616697.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pancreaticoduodenectomy, Afferent loop decompression, POPF, Postoperative complication, Pancreatic malignancy","lastPublishedDoi":"10.21203/rs.3.rs-8354959/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8354959/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClinically relevant postoperative pancreatic fistula (CR‑POPF) remains a key driver of morbidity after pancreaticoduodenectomy (PD). Afferent loop decompression (ALD) has been proposed to lower intraluminal pressure and reduce the risk of pancreatojejunostomy leak.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a study at a single HPB unit (August 2024\u0026ndash;July 2025) with a prospective cohort of 20 consecutive ALD cases compared with 60 propensity score matched historical controls. All the patients included in the study underwent Pylorus Resecting pancreaticoduodenectomy (PRPD) with Pancreaticojejunostomy anastomosis by modified Blumgart technique. Primary outcome was CR‑POPF (ISGPS Grade B/C). Secondary outcomes included delayed gastric emptying (DGE), post‑pancreatectomy hemorrhage (PPH), bile leak, and length of hospital stay.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIncidence of CR‑POPF was lower in the ALD group (10% vs 20%), however it was not statistically significant. Notably, grade B DGE occurred in 0% of ALD vs 46.7% of non‑ALD patients, and a significantly shorter length of hospital stay (12.2 vs 16.3 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PPH and bile leak occurred only among non-ALD patients, though events were infrequent. On univariate analysis, higher CA19‑9 (log‑transformed), BMI, and COPD/bronchial asthma were associated with increased odds of CR‑POPF.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn this preliminary matched analysis, ALD was associated with markedly lower DGE and length of hospital stay. However, the reduction in CR-POPF did not reach statistical significance.\u003c/p\u003e","manuscriptTitle":"Afferent Loop Decompression and Outcomes After Pancreaticoduodenectomy: Hybrid Cohort with Propensity Score Matching","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:23:43","doi":"10.21203/rs.3.rs-8354959/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd1ddacc-ebcd-41c2-abea-ece56467a467","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-15T04:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:23:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8354959","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8354959","identity":"rs-8354959","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}