Validation of two-stage pancreatojejunostomy after pancreatoduodenectomy for patients with a soft pancreatic texture and assessment of the remnant pancreas texture before second surgery.

Background: Two-stage pancreatojejunostomy (PJ) after pancreatoduodenectomy (PD) is one of the methods available for minimizing the possibility of grade C postoperative pancreatic fistula (POPF), especially in patients with a soft pancreatic consistency. Methods: We studied 131 patients with a soft pancreatic texture who underwent initial PD without PJ. The pancreatic tube was exteriorized through the abdominal wall incision. Three months later, we performed PJ, except for four patients died of recurrence. The remaining 127 patients underwent two-stage PJ. To assess the changes in pancreatic consistency after PD, computed tomography (CT) attenuation of the pancreas was measured before PD and compared with that after PD in 36 patients. Results: After initial PD, none of the patients suffered grade C POPF and postoperative mortality was zero. After the second operation, none of the patients suffered grade C POPF. One patient died due to recurrence of cancer. There was no mortality attributable to any adverse effect of POPF. The postoperative mortality rate was 0.7%. At the time of two-stage PJ, surgeons confirmed that texture of the remnant pancreas had changed from soft to hard. CT attenuation of the remnant pancreas before PJ was significantly lower than that of the pancreas body before PD (32.3 ± 10.0 vs. 40.5 ± 8.2, Conclusion: Two-stage PJ can be considered to minimize likelihood of grade C POPF. The changes in CT attenuation before PD and before PJ provide objective confirmation of a change in pancreatic texture from soft to hard, thus largely accounting for the reduced incidence of fatal POPF.