This prospective study evaluates whether preoperative endoscopic ultrasound elastography (EUS-E) can predict pancreatic texture during surgery and risk of postoperative pancreatic fistula (POPF) in 100 patients undergoing pancreaticoduodenectomy. EUS-E measures pancreatic stiffness preoperatively. Intraoperative texture ("soft" or "hard") is assessed by surgeons blinded to EUS-E results. POPF is graded using ISGPF criteria. Predictive accuracy of EUS-E will be analyzed statistically.

Pancreaticoduodenectomy is a complex surgery with significant morbidity, primarily due to postoperative pancreatic fistula (POPF). Soft pancreatic texture is a major risk factor for POPF. Endoscopic ultrasound elastography (EUS-E) is a promising tool for assessing tissue stiffness. This study will prospectively enroll patients undergoing PD. Preoperative EUS-E will be performed, and intraoperative pancreatic texture will be assessed by the surgeon. Postoperative outcomes, especially POPF, will be meticulously recorded. The study will analyze the diagnostic accuracy of EUS-E for pancreatic texture, its correlation with POPF severity,, as well as the impact on patient outcomes. Data will be collected from medical records, EUS reports, surgical notes, and pathology reports, with strict quality control and confidentiality measures. Statistical analysis will include Receiver Operating Characteristic (ROC) curve analysis for accuracy, and regression analyses to identify predictors and assess impact on outcomes.

In this study, blinding (masking) is implemented as follows:

• Surgeons are blinded to the results of the preoperative endoscopic ultrasound (EUS) elastography. They do not have access to the pancreatic stiffness measurements before or during surgery, ensuring their intraoperative assessment of pancreatic texture remains unbiased.
• Outcome assessors-those evaluating postoperative pancreatic fistula (POPF) and other clinical outcomes-are also blinded to both the preoperative elastography results and the intraoperative texture assessment. This reduces the risk of detection bias when determining study endpoints.

Inclusion Criteria:

• Adult patients aged 18 years or older.

• Patients scheduled for elective pancreaticoduodenectomy (PD) due to pancreatic head or periampullary disease, including but not limited to:

  • Pancreatic cancer (all stages eligible if resectable)
  • Periampullary cancer
  • Bile duct cancer
  • Duodenal cancer

• Patients deemed suitable for PD by the multidisciplinary pancreatic surgery team based on preoperative imaging and clinical evaluation.

• Adequate organ function and physiological reserve to undergo major abdominal surgery, as determined by clinical assessment and anesthesiology evaluation.

  • Ability to provide written informed consent and comply with study procedures.

Exclusion Criteria:

• Evidence of distant metastases or locally advanced unresectable disease on preoperative imaging or clinical evaluation (e.g., liver metastases, peritoneal carcinomatosis, involvement of major vessels beyond resectability).
• Previous pancreatic surgery or total pancreatectomy.
• Chronic pancreatitis confirmed by clinical, radiological, or histological criteria that could confound pancreatic stiffness assessment.
• Severe comorbidities or American Society of Anesthesiologists (ASA) physical status classification IV or higher, making the patient unfit for surgery.
• Preoperative serum albumin less than 2.5 g/dL, indicating severe malnutrition.
• Patients undergoing neoadjuvant chemotherapy or radiotherapy prior to surgery.
• Pregnancy or lactation.
• Contraindications to EUS (e.g., esophageal obstruction)

The study population includes adults aged 18 and older scheduled for elective pancreaticoduodenectomy (PD) for resectable pancreatic head or periampullary diseases, such as pancreatic cancer, periampullary cancer, distal bile duct cancer and duodenal cancer. Patients must be medically fit for major surgery, with adequate organ function and physiological reserve, based on clinical and anesthesiology assessments. Exclusions apply to those with distant metastases, locally advanced unresectable tumors, prior pancreatic surgery, or chronic pancreatitis to avoid confounding tissue assessment. Patients often present with symptoms like jaundice or abdominal discomfort and are managed in specialized pancreatic centers with multidisciplinary care. This cohort is appropriate for evaluating preoperative endoscopic ultrasound elastography as a tool to predict intraoperative pancreatic texture and postoperative pancreatic fistula risk.