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Radical surgery was postponed until the serum total bilirubin levels decreased to <10 mg/dl. A pylorus-preserving PD (PpPD) Rapamycin was generally indicated for the majority of cases, and in some cases a conventional PD was performed based on the tumor location or a requirement for lymphadenectomy. The pancreatic parenchyma was dissected using laparoscopic coagulating shears. All pancreatic remnants were reconstructed with end-to-side pancreaticojejunostomy, followed by Child's modified procedure for reconstruction of the digestive tract. Duct-tomucosa anastomosis was used for pancreaticojejunostomy in all cases by two surgeons (N.A. and F.O.). In brief, the jejunal serosa was resected a little smaller than the size of the pancreatic duct, and the mucosa of the jejunum was exposed at the anastomotic point. Then the anastomosis was formed between the pancreatic Obeticholic Acid duct and the entire jejunal wall using eight interrupted 6?C0 absorbable monofilament sutures (PDS-II, ETHICON Inc., Bridgewater, NJ). A one-layer suture technique [14] was used to approximate the pancreatic stump to the jejunal wall. Polyvinyl chloride tubes (7.5-F in diameter; Sumitomo Bakelite, Tokyo, Japan) were inserted as internal stents in all cases regardless of the texture of the pancreatic remnant or the size of the pancreatic duct. Fibrin glue (Beriplast; Behring Inst GmbH, Marburg, Germany) was applied to the sutured surface. Omental wrapping of skeletonized major vessels was performed as described previously [15]. Two round silicone, closed-suction drains were placed, one close to the ventral side of the pancreatic anastomosis and the other find more close to the posterior side of the biliary anastomosis. The peripancreatic drains were used to collect drainage fluid and for the assessment of amylase levels. The drains were removed 10 days after the operation in patients with no complications. In patients with POPF, the drains remained in place until cessation of the leakage was confirmed. The amylase level of the drainage fluid was routinely evaluated on the third and seventh postoperative days, and in cases with POPF it was re-evaluated periodically until the tube was removed. POPF was treated by continuous efficient drainage by the placement of the silicone tube with its periodical exchange, and additional antibiotics were administered if signs of infection were observed. Oral intake was never prohibited during POPF treatment. All patients received prophylactic antibiotics (cefmetazole 1 g, intravenously) every 4 h during the operation and twice a day from the first to third postoperative day.

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