“Pancreatoduodenectomy (PD) is the gold standard surgical procedure performed for both benign and malignant diseases of the pancreas and periampullary region. Since the introduction of PD by Whipple in 1941, the treatment of the pancreatic stump was felt as
primary issue due to the frequency of the complications. Advances in medical and surgical care have made the mortality rate after PD declined dramatically (0e5%), even in centres with experienced surgeons. However, the morbidity rate remains quite high, approaching the 50%. The most common complications after PD are pancreatic fistula, late gastric empty, haemorrhage, hepatic-jejunostomy leakage, wound infection and intraabdominal abscess, which affect mortality rate, hospitalization and costs. At present, pancreatic fistula (PF) is the most significant complication, with a rate ranges from 5% to 40% even in tertiary centers. About the 40% of the patient deaths are the results of septic and haemorrhagic complication following PF. Although, attempting to reduce complications, many refinements of the cur-
rent surgical techniques, pancreatico-jejunostomy, pancreaticogastrostomy and duct occlusion, have been proposed. Nevertheless, the best method to manage the pancreatic stump is still debated.”

“Eleven years after its definition, postoperative pancreatic fistula (POPF) still remains one of the most harmful complications after pancreatic resection. Despite all the advances and technical modifications developed during this past decade to prevent POPF, the incidence of this dreaded complication still ranges between 3–45 % of pancreatic operations at high-
volume centers. Updating the ISGPF classification is both relevant and clinically important,
because POPF remains the single main determinant of serious postoperative morbidity and mortality related to pancreatic resection and plays a major role in terms of operation-related mortality, morbidity, hospital stay, and economic impact.”

“Based on the literature since 2005 investigating the validity and clinical use of the original
International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former “grade A postoperative pancreatic fistula” is now redefined and called a “biochemical leak,” because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require eoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula.”