As shown in Fig. 4, the pancreatic stump is sufficiently was reported. some in a conventional procedure, that is, the procedure that anastomoses the pancreatic stump to the posterior wall of the stomach from the outside. invaginated into the gastric lumen, and this guarantees adequate drainage of the pancreatic juice secreted from the accessory pancreatic ducts on the cross-section planes. The main pancreatic duct was incannulated using a short internal stent and then fixed with an absorbable suture. This is principally for facilitating identification of the Wirsung duct and avoiding inadvertently suturing it dur- ing the anastomosis. With regard to the pancreatic fistula observed in the present study, it occurred in the early phase of our experi- ence and in the case with a very soft pancreatic texture. Excessive traction to the stay sutures in order to insert the pancreatic stump into the gastric lumen damaged the soft pancreas and this resulted in partial amputation in the pancreatic stump. We estimated that this damaged por- tion of the pancreas slipped down out of the stomach and evoked leakage. This pancreatic fistula was resolved with conservative therapy and it was classified as grade B ac- cording to the ISGPF criteria. Afterward, this excessive traction was prevented by obtaining an adequate length of the posterior gastrotomy (3/4 the length of the pancreatic stump) and sufficient mobilization of the pancreatic stump (at least 4 cm) and pancreatic leakage never hap- pened again after this. In conclusion, this is a novel PG using two trans- pancreatic sutures with buttresses, and this procedure is performed through an anterior gastrotomy. We believe this technique is simple, secure and it possesses several ad- vantages over the conventional PG: it is very easy to per- form, it is less traumatic to the pancreatic stump, it can be performed through a mini-laparotomy due to the good vi- sion and straight sutures and it is secure owing to anchor- ing the invaginated pancreatic stump to the stomach pos- terior wall with buttresses. However, to determine its su- periority over the conventional procedures, this operative technique should be more comprehensively evaluated in a larger series. A novel pancreaticogastrostomy CONFLICTS OF INTEREST No potential conflict of interest relevant to this article REFERENCES 1. Chen HW, Lai EC, Su SY, Cai YF, Zhen ZJ, Lau WY. Modified technique of pancreaticojejunal anastomosis with invagination following pancreaticoduodenectomy: a cohort study. World J Surg 2008;32:2695-700. 2. Zeng Q, Zhang Q, Han S, Yu Z, Zheng M, Zhou M. Efficacy of somatostatin and its analogues in prevention of post- operative complications after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. Pancreas 2008;36:18-25. 3. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. 4. Sledziński Z, Kostro JZ, Zadrozny D, Pirski I, Lukiański M, Głowacki J. Results of pancreaticogastrostomy after pan- creaticoduodenectomy in 159 consecutive cases. Pancrea- tology 2008;8:36-41. 5. Payne RF, Pain JA. Duct-to-mucosa pancreaticogas- trostomy is a safe anastomosis following pancreaticoduo- denectomy. Br J Surg 2006;93:73-7. 6. Aranha GV, Aaron JM, Shoup M. Critical analysis of a large series of pancreaticogastrostomy after pancreatico- duodenectomy. Arch Surg 2006;141:574-9. 7. Yang YL, Xu XP, Wu GQ, Yue SQ, Dou KF. Prevention of pancreatic leakage after pancreaticoduodenectomy by modified child pancreaticojejunostomy. Hepatobiliary Pan- creat Dis Int 2008;7:426-9. 8. Lai EC, Lau SH, Lau WY. Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 2009;144:1074-80. 9. Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbecks Arch Surg 2008;393:459-71. 10. Grobmyer SR, Kooby D, Blumgart LH, Hochwald SN. Novel pancreaticojejunostomy with a low rate of anasto- motic failure-related complications. J Am Coll Surg 2010;210:54-9. 11. Peng SY, Wang JW, Li JT, Mou YP, Liu YB, Cai XJ. Binding pancreaticojejunostomy-a safe and reliable anastomosis procedure. HPB (Oxford) 2004;6:154-60. 12. Ohigashi H, Ishikawa O, Eguchi H, Sasaki Y, Yamada T, Kishi K, et al. A simple and safe anastomosis in pan- creaticogastrostomy using mattress sutures. Am J Surg 2008;196:130-4. 13. Aranha GV, Hodul P, Golts E, Oh D, Pickleman J, Creech S. A comparison of pancreaticogastrostomy and pan- creaticojejunostomy following pancreaticoduodenectomy. thesurgery.or.kr 337