Tae Ho Hong, et al. cross-section of the pancreatic stump and they were suc- cessfully treated by endoscopy. One patient developed wound infection and this resolved with conservative treatment. DISCUSSION Pancreatoenteric anastomsis is quite different from the anastomosis between hollow viscera such as gastro- jejunostomy, jejunojejunostomy or colocolostomy. First of all, the nature of the two organs in pancreatoenteric anas- tomosis is disparate. One is solid and the other is tubular with a lumen. So, there is no landmark for the adequate thickness of the suture ‘bites’ between the two organs. Secondly, this solid organ has numerous accessory pancre- atic ducts as well as a main pancreatic duct on the cross-section planes, and these ducts secrete pancreatic juice and this might account for breaking down of the anastomosis if left undrained. Also, if these ducts are oc- cluded while performing anastomosis, then postoperative pancreatitis in the pancreatic remnant might occur, and this can contribute to the anastomotic failure. Third, the normal pancreas is so soft and fragile that pancreatic lacer- ation is inevitable during suturing with a needle or during tightening of the suture thread. This is more evident when a suture made with a curved needle traps only a small amount of pancreatic parenchyma. Fourth, among the two organs in the pancreatoenteric anastomosis, one is fixed and the other is relatively movable. So, the pancreatoen- teric anastomosis could be more vulnerable to disruption than others between hollow viscera. For these reasons, the management of a pancreatic rem- nant after PD has been of great concern to pancreatic sur- geons and numerous techniques to reduce the pancreatic fistula have been described such as PJ or PG, end-to-end or end-to-side anastomosis, invagination or duct-to-mucosa anastomosis, the use of an isolated Roux-en-Y limb, bind- ing PJ, the pancreatic duct stenting methods, application of topical adhesives and duct occlusion without pan- creatoenteric anastomosis [1,4-11,19]. We started to adapt PG after PD in 2001 because of the superiority of PG over the PJ: the proximity of the stomach and the pancreas, the 336 thick posterior wall and excellent blood supply of the stomach, a lack of enzyme activation in the stomach and fi- nally less tension on the anastomosis through the nasogas- tric continuous decompression of the stomach. We then revised the previous PG method based on the above mentioned analysis of the pancreatic anastomosis. In order to minimize the pancreatic laceration during su- turing with a needle or tightening of the suture thread, we introduced transpancreatic suture with a straightened needle instead of the conventional circumferential suture with a curved needle around the stump of the pancreas. This maneuver can also prevent full disruption of the pan- creas stump from the stomach by any possibility that there is a partial breakdown in the anastomosis. Moreover, in this improved PG method, only two sutures are applied on both edges of the pancreatic stump, which enabled further reducing the suture damage to the pancreatic parenchyma and shortening the overall time required for this anastomosis. Instead, this simplified PG method is com- pensated by including the stomach wall in both edges of the gastrotomy with buttresses during tightening of the suture thread, and this firmly anchors the gland to the stomach. Ohigashi et al. [12] also used straight sutures penetrating the pancreas in a U-like fashion and they re- ported a 0% pancreatic leakage rate with a shortened time required for the anastomotic procedure. They placed 4 to 8 pancreas-penetrating sutures (2 to 4 U-like loops) in ac- cordance with the diameter of the pancreatic stumps. These sutures are not tied promptly, but instead they are left loose until all of the U-like loops have been performed and tied. So, it seems very embarrassing if an unexpected bleeding occurs while the needle is penetrating the pan- creas before the completion of the U-like loops because the bleeding would stop when the sutures are firmly tied. The approach via the gastrotomy in the anterior gastric wall provides an excellent field of vision and consequently much easier performance of the anastomosis. The direct vision of the surgical field and only two straight sutures for the completion of this anastomosis enabled us to more decrease the size of the laparotomy in the cases of laparo- scopy-assisted PD. Further, the full-thickness suturing of the stomach wall from the inside spontaneously prevents the protrusion of gastric mucosa, which is very cumber- thesurgery.or.kr