during the surgery you have not significant bleeding and all anastomosis was done without any problem.

 I would insert a drain for the pancreaticojej/pancreaticogastric anastomosis and another one for the biliary-enteric anastomosis, at least.

I agree with Mauro Podda. Although drains will not decrease fistula rate, they will protect the patient in case of a fistula, because it will be drained.

At least a drain adjacent to the pancreatic anastomosis I will always use, because this is the most problematic anastomosis.

Single Jackson Pratt drain near the pancreatic anastomosis

2 drains, one the pancretico- jeujonostomy passing through the billiary anastomosis and the morrison space., and the  other one is pelvic drain for collections.

thanks for your replay

but are not you concern about infection with multiple open drainage?

Infection is a problem if the tube is kept unnecessarily too many days (more than 5).

One idea for drain adjacent to pancreatic anastomosis: You can determine amilase of the drained liquid in the first pos-op day, and if it is below 5000 U/l the probability of having a pancreatic fistula is low, and early remove of drain should be considered. If it is higher than 5000 U/l this decision should be postponed until 5th pos-op day.

Like in every types of abdominal surgery, drains kept in place too many days (essentially more than 5 days) without use/indication, increase the risk of infection.

According to the International Study Group for Pancreatic Fistula (Bassi C et al, 2005), drain amylase should be determined on post-operative day 3. If drain amylase is > than 3 times serum amylase, it indicates pancreatic fistula. 

JP or Nelaton tube drain running below both the PJ and GJ anastomoses. They do not decrease fistula rate and also have no role in early diagnosis of leakage, however they prevent loculation of leakage if present. The only way that proved to significantly reduce PJ leak is insertion of external transanastomotic PJ drain to drain pancreatic juice to the outside while allowing sound anastomotic healing without activation of pancreatic enzymes as they are prevented from contacting the alkaline bile.

A single drain tunnel across PJ and GJ  anastomosis. The drain to me help the surgeons more than patients. I had a patients that leaked after drain removal POD 7. Before then no evidence of leak.

two dreins: one behind bilio-digestive anastomosis, and the other one behind gastro-enteric anastomosis, until the pancreatic anastomosis. The latter is used to determinate lipase in 3^ e 5^ p.o.d.

I also use two dreins: one behind bilio-digestive anastomosis, and the other one behind gastro-enteric anastomosis, until the pancreatic anastomosis. The latter is used to determinate amilase in 3^ e 5^ p.o.d.

I use one Jackson Pratt drain just behind the bilioenteric  and pancreaticojejunal anastomosis. There is no need for roux n Y.

I use two draiins one behind biliodigestive anstomosie and the other  behingd gastroenteric anastomosis close to pancretojejunal anastomosis .I allways used two separated jejunal loops for reconstruction.This techique does not reduce the incidence of pancreatic fistula but reduces the severety of this event 

Dear Dr Tartaglla

Dear Dr Escartin

Dear Dr Dilek

Dear Dr Machado

Thanks very much for your attention and replies and sorry for my late response 

i have two experience of using double R en Y . it is safe but time consuming and now i use Bloomgart technique for pancreas anastomosis to prevent pancreas leak.

best regards