A modified perioperative strategy including ultrasonic pancreatic transection and early drain removal after pancreatoduodenectomy: a retrospective before-and-after study

Postoperative pancreatic fistula (POPF) remains a major complication after pancreaticoduodenectomy (PD). In July 2023, our institution introduced a modified perioperative management bundle that included ultrasonic pancreatic transection, changes in drain placement, and earlier drain removal. This retrospective single-center before-and-after study evaluated its association with postoperative outcomes after PD. A retrospective review was conducted of 100 consecutive patients who underwent PD. Group C included 50 patients treated between October 2020 and June 2023, and Group N included 50 patients treated between July 2023 and October 2025. Reconstruction was performed using duct-to-mucosa pancreaticojejunostomy with the modified Blumgart anastomosis in all cases. Pancreatic transection was performed using a scalpel in Group C and an ultrasonically activated device in Group N. All patients underwent internal pancreatic duct stent placement. Group N also underwent reduced drain placement and earlier drain removal. Perioperative outcomes were compared. Clinically relevant POPF was defined according to the 2016 ISGPS criteria. Group N showed significantly lower postoperative day 3 drain amylase levels and a lower incidence of clinically relevant POPF (36% vs. 4%). Drain replacement, major complications, and 30-day readmission rates were also significantly lower, whereas oral intake resumed earlier and hospital stay was shorter. In exploratory analyses, pancreatic texture and the modified perioperative management strategy were associated with clinically relevant POPF. In addition, Fistula Risk Score (FRS)-based assessment suggested that baseline fistula risk was not lower in Group N than in Group C. A modified perioperative management bundle including ultrasonic pancreatic transection and early drain removal was associated with lower rates of clinically relevant POPF after PD and may have contributed to improved short-term postoperative outcomes. Prospective studies are warranted to clarify causal relationships and disentangle the effects of individual perioperative components.