Pancreaticoduodenectomy (PD), also referred to as the Whipple procedure, remains the gold standard surgical intervention for periampullary malignancies [1]. It is also occasionally used for chronic pancreatitis [2] and trauma [3]. Despite advancements in surgical technique, perioperative care, and volume-based centralization of pancreatic surgery, morbidity following PD remains considerable, with reported rates of 30%-50% even in high-volume centers, while mortality has declined to below 5% in most specialized units [4]. One of the most dreaded complications following PD is the development of a postoperative pancreatic fistula (POPF).The incidence of clinically relevant POPF (CR-POPF) varies from 10% to 30%, depending on patient- and procedure-specific risk factors [5]. Major risk factors for CR-POPF include soft pancreatic parenchyma, small pancreatic duct diameter, high intraoperative blood loss, prolonged operative duration, preoperative biliary stenting, hypoalbuminemia, and malnutrition [5, 6]. Numerous strategies have been used to reduce the risk of POPF, including variations in surgical technique (such as pancreatojejunostomy versus pancreatogastrostomy), [7] use of somatostatin analogs, [8] reinforcement of anastomosis, and early drain removal. However, none have universally succeeded in eliminating the complication, especially in high-risk anatomical or physiological settings. In such settings, afferent loop decompression (ALD), achieved by placing a Ryle’s tube into the afferent limb, offers a theoretical advantage by decreasing pressure, reduced jejunal limb stasis, allowing unimpeded drainage of pancreatobiliary secretions during the early postoperative period and also postoperative cholangitis risk [9, 10, 11]. The technique of ALD has been described sporadically in the literature, none of these studies are randomized trials, suggesting that it may reduce the incidence of CR-POPF by lowering tension on the pancreatoenteric anastomosis [12]. This study, therefore, aims to add on further evidence regarding the role of intraoperative afferent loop decompression in preventing CR-POPF and other major postoperative outcomes - Delayed Gastric Emptying (DGE), Post pancreatectomy hemorrhage (PPH), bile leak, and Prolonged hospital stay.

This hybrid cohort study was carried out at a tertiary care teaching hospital in eastern India. Consecutive patients enrolled in the study between April 2024 to March 2025 underwent pylorus resecting pancreaticoduodenectomy (PRPD) with ALD (Prospective Group). The study population consisted of adults over 18 years of age undergoing PRPD with ALD. Ethical clearance was granted by the Institute's Ethical Committee review board. Informed consent was obtained from all participants prior to enrolment. A retrospective control group was formed from data of patients in the same unit who underwent PRPD without ALD during the course of four years preceding the study (Retrospective historical controls) (after 1:3 propensity score matching - nearest neighbor match, without replacement to match age, sex, preoperative biliary drainage, intraoperative blood loss, duct diameter and pancreas texture). Standardized mean differences (SMDs) were reviewed to assess matching adequacy. Fistula Risk Score (FRS) was calculated using gland texture, duct size, pathology, and intraoperative blood loss. Patients who had accidental removal of Ryle’s tube were excluded from study. The CONSORT diagrams for both cohorts are depicted in Figures 1 and 2. All patients in both groups underwent standard open PRPD. Reconstruction involved a Pancreaticojejunostomy (PJ) (modified Blumgart technique), followed by hepaticojejunostomy (HJ), antecolic gastrojejunostomy (GJ) and Feeding Jejunostomy (FJ - Witzel’s technique). Afferent loop decompression was done in ALD group by Intraoperatively guiding 16 Fr Ryle’s tube near HJ within 5 cm after completion of posterior layer of GJ. (Figure 3), whereas 16 Fr Ryle’s tube was placed in stomach in all control group. All surgeries were performed by two chief surgeons with experience in more than 30 cases and assisted by MCH resident doctors. As per study protocol Ryle’s tube (ALD decompression) was allowed continuous free external drainage and was removed on POD5 except in patients having clinical features of DGE for which it was removed once DGE settled. In both group patients were allowed oral clear liquids from post-operative day (POD) 4 if they were able to tolerate and didn’t have DGE, for which FJ was used for feeding purpose. Postoperative complications were recorded prospectively and defined according to ISGPS criteria for CR-POPF, DGE, and PPH. Bile leak was defined as per ISGLS criteria, and other complications were recorded using the Clavien-Dindo framework and summarized by Charlson Comorbidity Index (CCI). Major complications were defined as Clavien-Dindo grade III-V, and minor complications as grade I-II. Data collection included patient demographics, preoperative comorbidities, operative characteristics and postoperative complications, duration of hospitalization, unplanned reoperation, 30-day mortality, readmission and histopathological details. Statistical analyses were conducted using SPSS version 28.0. Continuous data are presented as means with standard deviations (SDs) and were analyzed using t tests or Mann-Whitney U tests when appropriate. Categorical variables are shown as proportions and were compared using chi-square or Fisher's exact tests. Logistic regression analysis was conducted to determine significant factors associated with DGE. A p-value of <0.05 was considered statistically significant. The study protocol was approved by the Institutional Ethics Committee, Institute of Medical Science and SUM Hospital IEC Registration No: ECR/627/Inst/OR/2014/RR-20, and written informed consent was obtained from all prospectively enrolled participants. The trial was registered with the Clinical Trial Registry India (CTRI), Trial No: CTRI/2025/12/098589. Our study adhered to the Declaration of Helsinki. Fig 1: Consort diagram. Flowchart of the case cohort. Fig 2: Consort diagram. Flowchart of the retrospective cohort Fig 3: Illustration (Left) and operative image of Afferent Loop Decompression (Right) with intraoperative guiding of Ryle’s tube after completion of posterior layer of GJ. (Middle)

This hybrid cohort study was carried out at a tertiary care teaching hospital in eastern India. Consecutive patients enrolled in the study between April 2024 to March 2025 underwent pylorus resecting pancreaticoduodenectomy (PRPD) with ALD (Prospective Group). The study population consisted of adults over 18 years of age undergoing PRPD with ALD. Ethical clearance was granted by the Institute's Ethical Committee review board. Informed consent was obtained from all participants prior to enrolment. A retrospective control group was formed from data of patients in the same unit who underwent PRPD without ALD during the course of four years preceding the study (Retrospective historical controls) (after 1:3 propensity score matching - nearest neighbor match, without replacement to match age, sex, preoperative biliary drainage, intraoperative blood loss, duct diameter and pancreas texture). Standardized mean differences (SMDs) were reviewed to assess matching adequacy. Fistula Risk Score (FRS) was calculated using gland texture, duct size, pathology, and intraoperative blood loss. Patients who had accidental removal of Ryle’s tube were excluded from study. The CONSORT diagrams for both cohorts are depicted in Figures 1 and 2. All patients in both groups underwent standard open PRPD. Reconstruction involved a Pancreaticojejunostomy (PJ) (modified Blumgart technique), followed by hepaticojejunostomy (HJ), antecolic gastrojejunostomy (GJ) and Feeding Jejunostomy (FJ - Witzel’s technique). Afferent loop decompression was done in ALD group by Intraoperatively guiding 16 Fr Ryle’s tube near HJ within 5 cm after completion of posterior layer of GJ. (Figure 3), whereas 16 Fr Ryle’s tube was placed in stomach in all control group. All surgeries were performed by two chief surgeons with experience in more than 30 cases and assisted by MCH resident doctors. As per study protocol Ryle’s tube (ALD decompression) was allowed continuous free external drainage and was removed on POD5 except in patients having clinical features of DGE for which it was removed once DGE settled. In both group patients were allowed oral clear liquids from post-operative day (POD) 4 if they were able to tolerate and didn’t have DGE, for which FJ was used for feeding purpose. Postoperative complications were recorded prospectively and defined according to ISGPS criteria for CR-POPF, DGE, and PPH. Bile leak was defined as per ISGLS criteria, and other complications were recorded using the Clavien-Dindo framework and summarized by Charlson Comorbidity Index (CCI). Major complications were defined as Clavien-Dindo grade III-V, and minor complications as grade I-II. Data collection included patient demographics, preoperative comorbidities, operative characteristics and postoperative complications, duration of hospitalization, unplanned reoperation, 30-day mortality, readmission and histopathological details. Statistical analyses were conducted using SPSS version 28.0. Continuous data are presented as means with standard deviations (SDs) and were analyzed using t tests or Mann-Whitney U tests when appropriate. Categorical variables are shown as proportions and were compared using chi-square or Fisher's exact tests. Logistic regression analysis was conducted to determine significant factors associated with DGE. A p-value of <0.05 was considered statistically significant. The study protocol was approved by the Institutional Ethics Committee, Institute of Medical Science and SUM Hospital IEC Registration No: ECR/627/Inst/OR/2014/RR-20, and written informed consent was obtained from all prospectively enrolled participants. The trial was registered with the Clinical Trial Registry India (CTRI), Trial No: CTRI/2025/12/098589. Our study adhered to the Declaration of Helsinki. Fig 1: Consort diagram. Flowchart of the case cohort. Fig 2: Consort diagram. Flowchart of the retrospective cohort Fig 3: Illustration (Left) and operative image of Afferent Loop Decompression (Right) with intraoperative guiding of Ryle’s tube after completion of posterior layer of GJ. (Middle)

Patient characteristics The study enrolled 20 consecutive patients who underwent PRPD with ALD. The patients had a mean age of 57.30±11.00 years and a median age of 59 years, with females comprising 55% of the group. The average body mass index (BMI) was 23.19±2.34 kg/m2. The most frequently reported initial symptoms were jaundice (95%, n = 19) and pain in abdomen (85%, n = 17). Comorbidities included diabetes (25%, n = 5), and hypertension (25%, n = 5). Additionally, 90.0% (n = 18) had undergone preoperative biliary stenting. The mean hemoglobin was 11.27±1.40 g/dL, and mean total bilirubin was 2.28±3.72 mg/dL. The mean operative time was 403.5±31.16 minutes, and the average intraoperative blood loss was 312.5±79.26 mL; 25% (n = 5) received one unit of intraoperative transfusion. Intraoperatively, the pancreatic texture was described as soft in 8 patients (40.0%), and firm in 12 patients (60%), while the pancreatic duct diameter averaged 4.5±2.06 mm. Table 1. Table 1: Baseline Demography and Clinical Characteristics Characteristic ALD Group Non-ALD Group p-Value Age 57.30±11.00 52.33±12.68 0.101 Female 11(55%) 21(35%) 0.120 Male 9(45%) 39(65%) 0.120 BMI 23.19±2.34 23.55±3.31 0.600 Jaundice 19 (95.0%) 37 (61.7%) 0.004 Pain in abdomen 17 (85.0%) 26 (43.3%) 0.002 Pruritus 9 (45.0%) 13 (21.7%) 0.083 GI Bleed 0 (0.0%) 1 (1.7%) 1.000 Anorexia 9 (45.0%) 14 (23.3%) 0.117 Weight loss 2 (10.0%) 4 (6.7%) 0.637 Stented 18 (90.0%) 24 (40.0%) 0.001 DM 5 (25.0%) 19 (31.7%) 0.778 HTN 5 (25.0%) 7 (11.7%) 0.278 BA/COPD 0 (0.0%) 2 (3.3%) 1.000 Hemoglobin 11.27±1.40 11.02±1.75 0.523 Creatinine 0.79±0.35 1.08±0.27 0.003 Urea 20.16±9.39 30.97±7.15 <0.001 Total Bilirubin 2.28±3.72 6.06±6.24 0.002 Direct Bilirubin 1.74±3.08 5.00±5.39 0.001 SGOT 72.30±132.86 76.33±42.86 0.895 SGPT 80.90±140.30 75.88±39.15 0.876 ALP 225.90±197.13 455.92±211.28 <0.001 Albumin 3.66±0.40 3.53±0.60 0.277 PT 10.77±0.90 11.00±0.93 0.315 INR 1.01±0.09 1.16±0.15 <0.001 Pancreatic duct diameter in mm 4.5±2.06 5.3±2.42 0.160 PD dilated (>3mm) 12/20 (60.0%) 37/60 (61.7%) 1.000 CCI Index 0.40±0.60 0.42±0.70 0.918 After matching, traditional POPF risk factors were broadly comparable: mean Fistula Risk Score (FRS) did not differ significantly between ALD and non-ALD groups, and the proportion of dilated ducts (>3 mm) was similar (60.0% vs 61.7%; p ≈ 1.00) Comparative analysis Baseline characteristics were similar between the two groups, mean BMI was comparable in ALD and non-ALD groups (23.19 vs. 23.55, p = 0.6). Preoperative biliary stenting was performed more frequently in the ALD group (90% vs. 40%, p = 0.001). Patients in the ALD group had a higher incidence of anorexia (45%) than those in the non-ALD group (23.3%) (p = 0.117), and weight loss was also more prevalent in the ALD group (10% vs. 6.7%, p = 0.637). The intraoperative data demonstrated that the mean operative time was 403.5 minutes in the ALD group compared to 396.88±34.31 minutes in the non-ALD group, a difference that did not reach statistical significance. Likewise, estimated blood loss was similar between the two groups, with the ALD group averaging 312.5 ml and the non-ALD group averaging 450.16±162.38 ml, suggesting that the inclusion of ALD did not influence surgical duration or blood loss. There was also no significant difference between groups in intraoperative blood transfusion rates. The pancreatic duct diameter tended to be smaller in the ALD group (4.5±2.06 mm vs 5.3±2.42 mm), although this did not reach statistical significance (p ≈ 0.16). The average duration of hospitalization following surgery was 12.2±3.19 days. In the ALD cohort, periampullary malignancies predominated in 18/20 patients (90%), with the remaining cases comprising pancreatic head carcinoma in 1 (5%), and distal cholangiocarcinoma in 1 (5%). Histologically, adenocarcinoma was the dominant type in 19/20 patients (95%), with only 1 patient (5%) harboring benign pathology. In the non-ALD historical controls, periampullary tumors accounted for 31/60 resections (52.5%), followed by distal cholangiocarcinoma in 9 (15.0%), pancreatic head tumors in 8 (13.3%), and benign periampullary or pancreatic lesions in 11 (18.3%). Overall, adenocarcinoma represented the commonest histologic type (45/60, 75.0%), with smaller numbers of IPMN (2/60, 3.3%), solid pseudopapillary tumor (1/60, 1.7%), and neuroendocrine carcinoma (1/60, 1.7%), while 11/60 (18.3%) resections yielded benign pathology. Within ALD group, 65.0% (n = 13/20) had Biochemical Leak, and 10% had CR-POPF (Grade B POPF n=2, Grade C POPF n=0), whereas in non-ALD group, 33.0% (n = 20/60) had Biochemical Leak, and 20% had CR-POPF (Grade B POPF n=12, Grade C POPF n=0). Table 2. Table 2: POPF Grades POPF Grade ALD Group Non-ALD Group p-Value No POPF 5 (25.0%) 28 (46.7%) 0.149 CR-POPF POPF Grade B 2 (10.0%) 12 (20.0%) 0.499 POPF Grade C 0 (0.0%) 0 (0.0%) 1.000 Additional postoperative outcomes were thoroughly examined. The analysis revealed that no DGE was observed in the ALD group, whereas 10 (16.7%), 17 (28.3%) and 1 (1.7%) patient in the non- ALD group experienced DGE Grade A, B and C respectively. SSIs occurred in 2 ALD patients (10%) and 15 non-ALD patients (25%), with no statistically significant difference between the groups. In the ALD group, there were no cases of PPH; the non-ALD group showed 3 cases (5%) of Grade B, and 1 case (1.7%) of Grade C PPH. There were no cases of bile leak in the ALD group vs 6 cases (10%) had bile leak in non-ALD group. Table 3. Table 3: DGE, PPH, and Bile Leak Complication Grade ALD Group Non-ALD Group p-Value DGE No DGE 20 (100.0%) 32 (53.3%) <0.001 DGE Grade A 0 (0.0%) 10 (16.7%) 0.059 DGE Grade B 0 (0.0%) 17 (28.3%) 0.005 DGE Grade C 0 (0.0%) 1 (1.7%) 1.000 Overall DGE 0 (0.0%) 28 (46.7%) <0.001 PPH No PPH 20 (100.0%) 56 (93.3%) 0.567 PPH Grade A 0 (0.0%) 0 (0.0%) 1.000 PPH Grade B 0 (0.0%) 3 (5.0%) 0.569 PPH Grade C 0 (0.0%) 1 (1.7%) 1.000 Bile Leak No Bile Leak 20 (100.0%) 54 (90.0%) 0.328 Bile Leak 0 (0.0%) 6 (10.0%) 0.328 Other complications such as ascites, surgical site infection (SSI), urinary tract infection, ileus, and intestinal anastomosis leak did not differ significantly between the groups. The mean postoperative hospital stay was significantly shorter for the ALD group (12.2 days) compared to the non-ALD group (16.3±6.67 days) (p < 0.001). Postoperative morbidity assessed using the Clavien-Dindo classification demonstrated a lower proportion of major complications (≥ Grade IIIa) in the ALD group (5%, n=1/20) compared with the non-ALD group (15%, n=9/60), although this difference did not reach statistical significance (p = 0.27). No patient in either cohort experienced Grade IV or 30-day mortality. There were no readmissions in either group, and no patient in either cohort had received neoadjuvant chemo- or chemoradiotherapy. Table 4: Global outcomes Outcome ALD Group Non-ALD Group p-Value CR-POPF (ISGPS Grade B/C) 2(10.0%) 12(20.0%) 0.499 Any DGE (ISGPS Grade A/B/C) 0(0.0%) 28(46.7%) <0.001 PPH (ISGPS Grade A/B/C) 0(0.0%) 4(6.7%) 0.567 Bile Leak 0(0.0%) 6 (10.0%) 0.328 Surgical site infection 2(10.0%) 15(25.0%) 0.214 Length of hospital stay, days 12.2±3.19 16.3±6.67 0.001 Reoperation for complications 0(0.0%) 2(3.3%) 1.000 CCI Index (mean±SD) 0.40±0.60 0.42±0.70 0.918 Using the original Callery Fistula Risk Score (FRS) (gland texture, pathology, duct diameter and intraoperative blood loss) there was no significant difference in mean FRS or FRS risk categories between ALD and non-ALD groups after matching (Table 5), suggesting broadly comparable intrinsic POPF risk profiles. Table 5: FRS Table Parameter ALD Group Non-ALD Group p-Value FRS total score (mean±SD) 3.0±1.8 3.6±1.6 0.146 Negligible risk (FRS 0) subgroup 0(0.0%) 1 (1.7%) 1.000 Low risk (FRS 1-2) 9 (45.0%) 16 (26.7%) 0.165 Moderate risk (FRS 3-6) 11 (55.0%) 41 (68.3%) 0.293 High risk (FRS 7-10) 0(0.0%) 2 (3.3%) 1.000 Univariate analysis Univariate analysis demonstrated that most blood parameters did not have a significant association with POPF. The exceptions were the tumor marker CA19-9 (p = 0.006), BMI (p = 0.02), and COPD/BA (p = 0.038) which showed a significant relationship with POPF. There were no significant associations identified between intraoperative predictors including pancreatic duct diameter, gland texture, intraoperative blood loss or transfusion, or the duration of surgery and POPF. Table 6. Table 6: Univariate Logistic Regression: Predictors of CR‑POPF Predictor Estimate Z p-value Odds Ratio 95% CI Lower 95% CI Upper CA 19-9, log10(U/mL+1) 1.901 2.753 0.006 6.694 1.73 25.911 BMI (kg/m²) 0.247 2.325 0.02 1.28 1.039 1.576 COPD/BA (Y) 3.281 2.077 0.038 26.6 1.203 588.082 Age (per year) 0.027 1.016 0.31 1.027 0.975 1.083 Male sex (vs female) -0.495 -0.836 0.403 0.61 0.191 1.945 Diabetes (Y) 0.318 0.512 0.608 1.374 0.407 4.637 Hypertension (Y) -0.069 -0.082 0.934 0.933 0.181 4.817 Abdominal pain (Y) -0.893 -1.462 0.144 0.409 0.124 1.355 Jaundice (Y) 0.537 0.764 0.445 1.711 0.431 6.786 Pruritus (Y) 0.065 0.099 0.921 1.067 0.297 3.836 GI bleeding (Y) 0.409 0.247 0.805 1.506 0.058 38.866 Anorexia (Y) -0.011 -0.016 0.987 0.989 0.276 3.545 Weight loss (Y) -0.064 -0.056 0.955 0.938 0.101 8.719 Preoperative stenting (Y) 0.227 0.383 0.702 1.255 0.392 4.017 Hemoglobin (g/dL) -0.201 -1.112 0.266 0.818 0.574 1.166 Total bilirubin (mg/dL) -0.001 -0.018 0.985 0.999 0.906 1.102 Direct bilirubin (mg/dL) 0.006 0.104 0.917 1.006 0.899 1.126 SGOT (U/L) -0.005 -0.702 0.483 0.995 0.981 1.009 SGPT (U/L) -0.004 -0.593 0.553 0.996 0.983 1.009 ALP (U/L) 0.002 1.295 0.195 1.002 0.999 1.004 Albumin (g/dL) -0.426 -0.778 0.437 0.653 0.223 1.912 PT (s) -0.305 -0.898 0.369 0.737 0.379 1.435 INR 0.066 0.034 0.973 1.068 0.025 45.143 Urea (mg/dL) 0.023 0.689 0.491 1.023 0.959 1.091 Creatinine (mg/dL) 0.424 0.461 0.645 1.528 0.252 9.256 Soft gland (vs hard) -0.693 -1.143 0.253 0.5 0.152 1.642 PD diameter (mm) 0.072 0.578 0.564 1.075 0.842 1.373 PD dilated (Y) -0.207 -0.347 0.729 0.813 0.252 2.618 OT Duration 0.135 0.542 0.588 1.145 0.701 1.869 Blood loss (per 100 mL) 0.087 0.487 0.627 1.091 0.767 1.552

Pancreaticoduodenectomy remains the standard treatment for periampullary tumors, distal bile duct tumors, and carcinoma of the pancreatic head. Although the mortality rate for this procedure has dropped to less than 2% in select high-volume centers, the morbidity rate continues to be relatively high. Among the complications that most affect morbidity is POPF and DGE. CR-POPF, as defined by the 2016 update from ISGPS, refers to pancreatic fistulas that necessitate a deviation from the routine clinical pathway such as percutaneous drainage, prolonged hospital stays, or reintervention, which excluded and redefined Grade a POPF category as biochemical leak requiring no intervention [13]. POPF often leads to secondary infections, intra-abdominal collections, hemorrhage, sepsis, and delayed recovery. One potential contributory factor in the pathophysiology of CR-POPF is increased intraluminal pressure within the afferent jejunal limb, which may strain the pancreatojejunostomy and hepaticojejunostomy anastomoses. This pressure can be exacerbated by postoperative ileus, edema, or kinking, leading to impaired outflow of pancreatic secretions [14]. Another factor implicated is infected bile and possibility of pancreatic enzyme activation contributing to development of post-operative pancreatitis and CR-POPF [15]. Various modifications have been implemented to reduce POPF. One of the surgical methods to reduce POPF and DGE - braun enteroenterostomy is based on similar hypothesis which has been recorded in literature with many studies showing mixed results on reducing POPF and DGE. From a physiological standpoint, ALD may mitigate DGE by reducing intraluminal pressure and edema at the gastrojejunostomy and by promoting more laminar flow of biliopancreatic secretions into the efferent limb, thereby improving early gastric emptying without adding an extra anastomosis, in contrast to Braun enteroenterostomy [16, 17]. Research on the impact of ALD on CR-POPF has yielded variable findings. In a study by Yin et al., which used continuous negative suction with ALD tube modification (added extra holes in gastric part of the tube) showed a statistically significant difference in incidence of POPF 23.4% vs 39.4% (p=0.018) in ALD and non-ALD groups respectively. Contrary to POPF, incidence of DGE was more in ALD group compared to non-ALD group, though it didn’t reach statistical significance (28.7% vs 20.2%, p = 0.175) [12]. Our findings differ in that ALD showed a marked reduction in DGE in our cohort, possibly reflecting differences in technique, tube position, or postoperative pathways and showed statistically significant decreased incidence of DGE (p < 0.001), a reduced rate of CR-POPF (10% vs 20%, p=0.499), and shortened hospital stay (although the last two did not reach statistical significance). Since both cohorts followed identical postoperative feeding protocols and all historical controls also had routine gastric Ryle’s tube placement, the observed difference in DGE is unlikely to be attributable to variations in postoperative care. However, with only 14 CR-POPF events in the entire matched cohort (2 vs 12), the analysis is clearly underpowered for this endpoint, and the non-significant p-value for CR-POPF (p = 0.499) is likely attributable to a Type II error rather than proof of no effect. These observations lend support to the hypothesized advantages of ALD [14, 15]. Univariate signals (CA19‑9, BMI, COPD/BA) align with the concept that systemic and disease‑related factors modulate fistula risk. Although these findings are encouraging, and suggest a potential protective effect of this reconstructive technique against CR-POPF, it warrants further investigation. Limitations Small sample size with 1:3 propensity matched controls; the hybrid design using a prospectively collected intervention cohort and retrospectively accrued historical controls; and residual confounding despite propensity matching. Several preoperative variables (e.g. jaundice, stenting, bilirubin and ALP) remained imbalanced after matching, and perioperative care protocols may have evolved over the 4-year historical control period, introducing temporal bias. In addition, because only two CR-POPF events occurred in the ALD arm, multivariable regression would violate conventional events-per-predictor rules and we therefore restricted our analysis to univariate exploratory signals. Conclusion This single‑center experience examines ALD as a pragmatic, low‑cost adjunct during PD. ALD appears safe and is associated with significantly lower DGE after PD in this preliminary matched cohort, with no statistically significant difference in CR-POPF. Prospective multicenter studies with larger cohorts are warranted to definitively establish the role of ALD in reducing DGE and CR-POPF in PD. Abbreviations • CR-POPF: Clinically relevant postoperative pancreatic fistula • PD: Pancreaticoduodenectomy • ALD: Afferent loop decompression • PRPD: Pylorus Resecting pancreaticoduodenectomy • DGE: Delayed gastric emptying • PPH: Post‑pancreatectomy hemorrhage • PJ: Pancreaticojejunostomy • HJ: Hepaticojejunostomy • GJ: Gastrojejunostomy • FJ: Feeding Jejunostomy • ISGPS: International Study Group of Pancreatic Surgery • SDs: Standard deviations • CTRI: Clinical Trial Registry India • FRS: Fistula Risk Score • SMD: Standardized Mean Difference • ISGLS: International Study Group of Liver Surgery • LOS: Length of stay • CCIl: Charlson Comorbidity Index Declarations • Clinical trial number: CTRI/2025/12/098589 • Ethics approval and consent to participate: This study was approved by the Institutional ethics committee, Institute of Medical Science (IMS) and SUM Hospital. IEC Registration No: ECR/627/Inst/OR/2014/RR-20.Written informed consent was obtained from all participants prior to inclusion in the study. The study followed the Declaration of Helsinki. • Consent to participate: Written informed consent was obtained from all participants prior to inclusion in the study. • Ethics approval and consent to participate: Written informed consent was obtained from all participants prior to inclusion in the study. Consent for publication: Written informed consent was obtained from all participants for publication of the study and accompanying images. • Funding: No funding was obtained for the study Availability of data and material: The data generated and/or analyzed during the current study are available from the corresponding author on reasonable request as an Excel sheet. • Competing interests: The authors declare that they have no competing interests • Authors Contributions: D.P and J.J wrote the main manuscript text and performed manuscript drafting. D.P collected clinical data and performed statistical analysis. S.S.M and P.B prepared the figures and tables. R.R.M and S.R.H critically revised manuscript for important intellectual content. All authors reviewed and approved the final manuscript.

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