Complications - Pancreaticoduodenectomy, pylorus-preserving, partial (OP according to Traverso)

• Bleeding
  e.g., portal vein injury
• Pancreatitis
  very fragile, soft pancreas or assistance error → pressure damage from hook
• Vascular Anatomy
  atypical right hepatic artery, unrecognized Dunbar syndrome! (compression syndrome of the trunk by the arcuate ligament) → gastroduodenal artery must be severed → division of the arcuate ligament
  NOTE: Electrocoagulation at the common hepatic duct (ischemic damage → later insufficiency)

• Anastomotic insufficiency of the pancreatico-jejunostomy (4-20%)
• Anastomotic insufficiency of the hepatico-jejunostomy (2-6%)
• (Erosion) bleeding (2-10%)
• Atony and gastric emptying disorder (8-15%)
• Pancreatitis and intra-abdominal abscess (2-6%)

Anastomotic insufficiencies represent the main problem and are usually recognized late due to uncharacteristic symptoms. If there is suspicion of insufficiency of the pancreatico-jejunostomy (pancreatic secretion via drains, unclear fever, CRP increase, leukocytosis, accompanying pancreatitis and atony), an abdominal CT with intravenous contrast should be performed immediately. In cases of local limitation, small leakage, and mild clinical course, a conservative therapeutic attempt can be made. An accompanying abscess can be drained interventionally, while more extensive findings indicate the need for relaparotomy. If the remaining pancreas is well-perfused and local conditions are favorable, oversewing of the insufficiency can be performed; otherwise, the anastomosis should be re-established. A remnant pancreatectomy is indicated in cases of advanced inflammatory surrounding reaction, severe remnant pancreatitis with hypoperfusion, and/or local necrosis formation.
In the case of insufficiency of the hepatico-jejunostomy, early revision is also required; small insufficiencies can be oversewn, but generally, the anastomosis must be re-established. Remnant pancreatitis, erosion bleeding, atony, and gastric emptying disorders are common accompanying phenomena of anastomotic insufficiency. Particularly, erosion bleeding, where the wall of the visceral vessels is usually digested by pancreatic juice due to insufficiency, represents a life-threatening and highly acute clinical picture that requires immediate relaparotomy (in rare cases, radiological intervention).