pancreaticoduodenectomy ( pd ) is one of the most complex surgical procedures in gastrointestinal surgery . with advances in diagnostic imaging and surgical techniques , the mortality rate of pd has decreased from 20% to 2% in high volume centers.1 leakage from pancreaticojejunostomy anastomosis is the most significant cause of postoperative morbidity and mortality . however , hepaticojejunostomy is also an important part of the surgical procedure for pd . any bile leak from hepaticojejunostomy anastomosis may cause morbidity through the occurence of bile peritonitis and intraabdominal abscess . this report focuses on the placement of a nasogastric tube into the common bile duct , a surgical technique that allows safe hepaticojejunostomy for pd . a 72-year - old female patient was admitted to our hospital with complaints of jaundice . her physical examination was normal except for jaundice . at the time of admission , the laboratory evaluation revealed alkaline phosphatase 314 iu / l ( reference : 50 - 150 ) ; gamma - glutamyltransferase 512 iu / l ( reference : 9 - 36 ) ; and cea and ca 19 - 9 levels were normal . abdominal magnetic resonance imaging ( mri ) and magnetic resonance cholangiopancreatography ( mrcp ) showed a distal bile duct obstruction with dilation of the common bile duct and intrahepatic bile ducts ( figs . 1 , 2 ) . endoscopic retrograde cholangiopancreatography ( ercp ) was performed due to an increase in bilirubin levels , and a plastic stent was placed into the common bile duct for endoscopic retrograde biliary drainange ( erbd ) . with a preliminary diagnosis of distal bile duct tumor , the patient was prepared for pd . during this period , fever ( 38.6c ) , an increased biluribin level of 11.06 mg / dl ( reference : 0.2 - 1.2 ) and a c - reactive protein ( crp ) level of 14.25 due to a legal holiday , the interventional radiology unit was not working , and thus percutaneous biliary drainage and repeat ercp could not be performed . as there was infected bile inside the common bile duct , the bile duct was washed out with isotonic solution . a cholangiogram was performed on the 10th postoperative day , from which it was found that there was total obstruction in the distal bile duct . the head of the pancreas was firm and enlarged without an obvious mass lesion , and thus pancreatic cancer was suspected . the common bile duct was prepared for anastomosis and pd was finally performed . due to the occurrence of inflammatory changes , a 12-fr nasogastric tube with additional holes was prepared and it was passed from the stomach and jejenum and placed into the common bile duct ( figs . hepaticojejunostomy anastomosis was performed in a one - layer fashion with 4/0 polydioxanone ( pds ) sutures . pancreaticojejunal anastomosis was performed in an end - to - side fashion with a catheter inside the pancreatic channel . the pathological examination of the surgical specimen revealed a pancreatic mass of 1.52 cm in diameter . the first pd was performed in 1909 and popularized by an american surgeon , allen whipple . pd has morbidity rates between 25% and 65%.234 hepaticojejunostomy is an important part of many surgical procedures including pd , liver transplantation , and palliative treatment of unresectable pancreaticobiliary tumors . the risk of bile leaks after pancreatic head resection varies between 2% and 12%.56 biliary leakage may be associated with intraabdominal abscess formation , biliary peritonitis , prolonged hospital stay , and mortality . due to the development of percutaneous techniques , most patients with anastomotic leakage can be managed without surgery . there are many studies that have investigated pancreaticojejunostomy anastomosis in pd . however , there are few studies relating to hepaticojejunostomy . although hepaticojejunostomy anastomosis is not a technically difficult anastomosis to perform , it can provide a challenging problem in patients with a small diameter bile duct or postinflammatory conditions . the use of a transanastomotic biliary stent is a well - known technique for difficult hepaticojejunostomy . herzog et al.7 investigated the role of t - tube placement into the anastomotic region in patients with difficult hepaticojejunostomy . there were 114 patients , of which 55 of them were managed with t - tube placement and 59 were not . biliary leakage was detected in 5 patients ( 9% ) with a t - tube and 9 patients ( 15% ) without a t - tube . seven percent ( 8/114 ) of patients required revisional laparotomy , 2% [ 1/55 ] of those with a t - tube and 12% [ 7/59 ] without a t - tube . it was concluded that hepaticojejunostomy with t - tube placement can not prevent biliary leakage but can reduce the severity of bile leaks , reducing the need for reoperation.7 suzuki et al.8 compared hepaticojejunostomies with stenting or without stenting . they concluded that the routine use of a biliary stent in hepaticojejunostomy is not justified . yoshida et al.9 used silicon drains for hepaticojejunostomy . in patients with hepatic hilar malignancies , they found that a 10-fr silicon drain with channels is superior to a 5-fr silicon drain with an internal lumen for internal biliary stenting for hepaticojejunostomy . yoshimi et al.10 performed internal stenting for hepaticojejunostomy and pancreaticojejunostomy in 11 patients with pancreaticoduodenectomy , in which there were only 4 minor leaks during the postoperative period . in our case , we used a 12-fr nasogastric tube to secure hepaticojejunostomy anastomosis . the nasogastric tube was active in the postoperative period and drained approximately 500 - 600 ml bile per day .
hepaticojejunostomy is an important part of many surgical procedures including pancreaticoduodenectomy . 
 biliary leakage from hepaticojejunostomy may be associated with intraabdominal abscess formation , biliary peritonitis , and even mortality . 
 a 72-year - old female patient was admitted to our hospital with obstructive jaundice . 
 after initial evaluation , she was diagnosed with distal common bile duct obstruction without accurate diagnosis . before planned pancreaticoduodenectomy , biliary drainage with a t - tube 
 was performed due to the presence of cholangitis . 
 after the first operation , pancreaticoduodenectomy was performed . 
 postinflammatory changes around the hilar region made the hepaticojejunostomy risky . 
 a bilio - digestive anastomosis was performed using a new technique . 
 a nasogastric tube was placed into the common bile duct proximal to the anastomosis . 
 the postoperative course of the patient was uneventful . 
 the use of a nasogastric tube as a stent in risky hepaticojejunostomies is a simple technique that can be beneficial .