Background : POPF is associated with a mortality of up to 25% apart from significant morbid sequelae related to abdominal sepsis and post pancreatectomy haemorrhage. Numerous strategies to curtail the risk of POPF and associated morbidity have been largely unsuccessful. The pancreaticoenteric anastomosis post pancreaticoduodenectomy in a high-risk pancreas represents a significant surgical and clinical challenge.

Methods : We present a video encompassing multiple intraoperative mitigation strategies we use in our unit at Tata Memorial Centre, Mumbai in a high risk pancreas to reduce the incidence and impact of CR-POPF.

Results : High risk pancreas are defined as the ones which lie in the high fistula risk zone with Fistula Risk Score between 7 to 10. The technical aspects of following mitigation strategies will be presented 1) Isolated Roux loop pancreaticojejunsotomy (PJ) 2) PJ technique with internal stent 3) PJ technique with external stent 4) Falciform ligament wrap over the PJ 3) Falciform ligament wrap over the gastroduodenal and common hepatic artery 4) Creating and placing a vascularised omentum in the PJ bed 5) Braun’s jejunojejunostomy 6) Drain placement technique 7) Use of fibrin sealants over major vessels

Conclusions : Although the evidence only supports the use of external stents in decreasing CR-POPF, we believe that the other mitigation strategies do play an important role in decreasing the CR-POPF rate if technically executed well, without any additional morbidity to the patient. Thus we present this video to demonstrate and discuss the technical nuances of these strategies in a high risk PJ.