tomy incision. Then, a suture buttress was inserted through each needle and finally a knot was made that in- cluded the stomach wall on the corner of the gastrotomy incision, with the aid of tissue forceps grasping the edges of the stomach wall upward (Fig. 4). A nasogastric tube was positioned alongside the anasto- mosis and the anterior gastrotomy was closed in two layers. The PG is drained with two Jackson-Pratt drains positioned in the retrogastric region in all cases. The vol- ume and amylase content of the drainage fluid were meas- ured every day. Octreotide is not routinely used intra- operatively or in the postoperative period, but H2 blocker is generally administered as prophylaxis for stress and marginal ulceration. We applied laparoscopy-assisted pylorus-preserving PD for the patients who had the preoperative diagnosis of benign or low-grade malignant periampullary disease. In this procedure, the choledochojejunostomy as well as the whole resection phase were performed with laparoscopy. A mini-laparotomy on an upper median abdominal wall was then performed and this was covered using a wound protector (Alexis Wound Protector/Retractor, Applied Medical Resources Co., Rancho Santa Margarita, CA, USA). Through the incision, the specimen was delivered and the PG in the manner explained above and an end-to-side duodenojejunostomy were performed se- quentially. Fig. 5 shows the location of trocar placement and the mini-laparotomy in the laparoscopy-assisted PD at our institution. Table 1. Pathological diagnosis in 21 patients Diagnosis Patients Pancreatic adenocarcinoma Ampullary adenocarcinoma Distal cholangiocarcinoma Duodenal adenocarcinoma Pancreatic endocrine tumor Intraductal papillary mucinous neoplasm Pancreatic trauma Total PD, pancreatoduodenectomy. thesurgery.or.kr 6 5 1 1 2 5 1 21 Laparoscopy- assisted PD (n) 3 2 4 9 A novel pancreaticogastrostomy RESULTS The patients consisted of 17 men and 4 women, with an average age of 55.1 years (range, 35 to 69 years) and their average body mass index was 23.9 kg/m2 (range, 20.8 to 27.8 kg/m2). The standard Whipple procedure was per- formed in only 1 case and the other 20 patients underwent a pylorus-preserving modification. Concomitant mesen- tericoportal vein resection was performed in 2 patients with pancreatic adenocarcinomas in this series. Nine pa- tients underwent laparoscopy-assisted pylorus preserv- ing PD and they had 4 intraductal papillary mucinous ad- enomas, 3 ampullary adenocarcinomas and 2 pancreatic endocrine tumors. The other 12 patients had various in- dications for PD (Table 1). Of the 21 patients, 11 (52.3%) pa- tients had a soft pancreatic texture and the remaining 10 (47.6%) had a firm pancreatic texture. The median esti- mated pancreatic duct size was 4 mm (range, 2 to 14 mm). The mean operating time was 378 minutes (range, 290 to 410 minutes) in the open PD cases and 418 minutes (range, 310 to 450 minutes) in the laparoscopy-assisted PD cases. The mean blood loss was 1,640 mL (range, 1,300 to 1,800 mL) in the open PD cases and 300 mL (range, 100 to 800 mL) in the laparoscopy-assisted PD cases. The mean dura- tion of postoperative hospitalization was 18.2 days (range, 9 to 28 days) in the open PD cases and 14.3 days (range, 8 to 16 days) in the laparoscopy-assisted PD cases. There were no operative or hospital deaths. Five com- plications (23.8%) occurred in 4 patients (Table 2). A pan- creatic fistula occurred in 1 patient (4.7%; grade B). He sub- sequently developed peripancreatic abscess, which was controlled by ultrasound-guided percutaneous drainage beside the operatively-placed drains, and delayed gastric emptying. Two patients experienced hemorrhage from the Table 2. Operative complications in 21 patients Complications Pancreatic fistula Delayed gastric emptying Bleeding from the pancreatic stump Wound infection Total Values are presented as number (%). Value 1 (4.7) 1 (4.7) 2 (9.5) 1 (4.7) 5 (23.8) 335