title: Pancreatico-enteric fistula post pancreatic duct ligation for delayed haemorrhage complicating pancreaticoduodenectomy.
abstract: BACKGROUND
  Pancreatic fistula remains the main cause for postoperative morbidity following pancreaticoduodenectomy. The coincidence of sentinel bleed prior to post pancreatectomy haemorrhage (PPH) and pancreatic fistula is associated with very high mortality.
  
  
  METHODS
  We report a case of pancreaticoduodenectomy complicated by postoperative leak and hematemesis. Severe delayed haemorrhage from the pancreatico-jejunostomy necessitated re-laparotomy and complete disconnection of the pancreatic anastomosis. Hemodynamic instability precluded a pancreatectomy or creation of a new anastomosis. A follow up MRI done 3 weeks after the patient's discharge demonstrated a fistulous tract causing a communication between both the pancreatic and biliary systems and the enteric loop.
  
  
  CONCLUSIONS
  Spontaneous development a pancreatico-enteric fistula despite ligation of the pancreatic duct and complete disconnection of the pancreatic anastomosis has never been reported in literature to date.
  
  
  CONCLUSIONS
  Pancreatic duct occlusion may be considered over a completion pancreatectomy or revisional pancreatic anastomosis in hemodynamically unstable and challenging cases.
authors.affiliation: General Surgery, Hamad Medical Corporation, General Surgery, Doha, Qatar.
authors.forename: Adarsh
authors.initials: A
authors.lastname: Vijay
authors.affiliation: Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar.
authors.forename: Islam
authors.initials: I
authors.lastname: Noaman
authors.affiliation: Radiology, Hamad Medical Corporation, General Surgery, Doha, Qatar.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Mahfouz
authors.affiliation: General Surgery, Hamad Medical Corporation, General Surgery, Doha, Qatar.
authors.forename: Mahwish
authors.initials: M
authors.lastname: Khawar
authors.affiliation: Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar.
authors.forename: Hatem
authors.initials: H
authors.lastname: Khalaf
authors.affiliation: Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar. Electronic address: ahmedaffandy@gmail.com.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Elaffandi
keywords: PD ligation; Pancreatico-enteric fistula; Pancreaticoduodenectomy