2.1. Surgical technique

All patients underwent pylorus-preserving proximal pancreaticoduodenectomy (PPPPD) with potentially curative intent. A full exploration of abdominal cavity was performed to exclude any possible sign of metastatic spread together with a careful assessment of the local extent of the tumor. Frozen sections were performed routinely at the pancreatic resection margin in all patients. In case of positive frozen section further resection of pancreatic parenchyma was performed. Tissue dissection, vessel ligation, complete removal of lymph nodes and an adequate haemostasis were ensured with LigaSure^® (Valleylab^®, Boulder, USA) since it was available. Reconstruction was performed by means of duodeno-jejunostomy, choledoco-jejunostomy, and pancreatico-jejunostomy on a separate jejuneal loop. The duodenum was transected proximally about 2–3 cm below the pylorus and distally in correspondence of the first jejunal loop, away from the uncinate process of pancreas. The proximal duodenum and proximal jejuneum were anastomosed with either an end to end anastomosis using Valtrac^® ring (Sherwood medical Company, St. Louis, Missouri, USA) ^[6] or an end to side anastomosis done by using circular stapler (Premium Plus CEEA^® 25, Tyco Healthcare Group LP). About 10–15 cm downstream, on the same jejuneal loop, an anastomosis with common bile duct or hepatic duct was fashioned with an hand-sewn suture at the antimesenteric side, with a 3/0 absorbable monofilament suture. A pancreaticojejunostomy was performed approximately 60 cm beyond the biliary anastomosis, creating a Roux-en-Y limb, led through the mesocolon, and attached to the capsule of body of pancreas (Fig. 1). Approximately 40 cm below the pancreaticojejunostomy an end to side jejuno-jejuneal anastomosis was created by using Valtrac^® ring (Fig. 2). After surgery, medical treatment was based on intravenous electrolyte and balanced fluid solutions. To prevent pancreatic leakage, three daily doses of 100 μg octreotide were given as subcutaneous injections for the first postoperative week. Parenteral nutrition via central venous catheter started on the second postoperative day.

Isolated Roux-en-Y reconstruction technique after pancreaticoduodenectomy.

Isolated Roux loop pancreaticojejunostomy performed by using Valtrac^® ring for the end to side jejuno-jejuneal anastomosis (Sherwood medical Company, St. Louis, Missouri, USA).