Pancreatic anastomotic technique during pancreaticoduodenectomy: does it boil down to surgeon preference?

Postoperative pancreatic fistula (POPF) remains one of the toughest challenges in pancreatic surgery and the principal cause of major morbidity and mortality after pancreaticoduodenectomy (PD) (1-3). Despite decades of refinement in surgical technique and perioperative care, the Achilles’ heel of PD still persists at the level of the pancreato-enteric (PE) anastomosis, where most clinically significant leaks originate (1,4). Furthermore, POPF functions as a major instigating factor for the occurrence of post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE), thereby creating a cascading path of POPF-related complications that greatly impact surgical recovery (1,5,6). In fact, clinically relevant POPF (CRPF), as defined by the International Study Group for Pancreatic Surgery (ISGPS) (4,7), is associated with increased length of stay (LoS), prolonged time in intensive care unit (ICU), higher chances of reoperation, lower rates and delayed start of adjuvant therapy, and up to 25% mortality (1,4,6-9).

Multiple studies have identified both non-modifiable and modifiable factors influencing the development of POPF following PD (10-15). Among the former, major factors include soft pancreatic texture and a small main pancreatic duct diameter (≤3 mm) (10-12,16). These are also closely related to risk factors such as low parenchymal fibrosis and benign or non-adencarcinoma histology (11,17,18). In addition, age, male gender, and high body mass index (BMI) with increased visceral fat have been considered unfavorable patient attributes (10,12,18-21). Many studies have attempted to evaluate the different anastomotic techniques employed in PD (2,22-42). In addition to early postoperative results, different reconstruction methods have been associated with varying long-term rates of exocrine pancreatic insufficiency (EPI) and diabetes (25,43). In a Cochrane systematic review by Cheng et al. from 2015 of 10 randomized controlled trials (RCTs), comparing pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG), no clear differences were identified in POPF rates, perioperative mortality, morbidity, or LoS (24). Similarly, in a recent Cochrane systematic review by Wu et al. of 11 RCTs, comparing different techniques of PJ (modified Blumgart, classic interrupted sutures, and invagination), no clear differences were identified in surgical complications, mortality, or LoS (28). However, due to variable methodologies and the relatively small sample sizes of many studies, the level of evidence was low, limiting the interpretation of the results.

In this recent multi-center RCT by Dorcarrato et al., 260 patients undergoing PD from across 13 tertiary hospitals in Spain were randomized to receive either a modified Blumgart PJ anastomosis or an invaginated PG (44). Aside from 13 patients initially allocated to the PG arm who required conversion to the PJ arm due to intraoperative difficulties, the groups were well randomized and comparable. However, the unidirectional crossover is unlikely to be incidental and may highlight potential limitations in the feasibility of invaginating PG in real-world anatomical settings, such as fibrotic, inflamed, or poorly mobile pancreatic stumps. From an analytical perspective, this asymmetry also carries important interpretative implications: intention-to-treat analysis may dilute true technique-related differences, whereas per-protocol analysis preferentially retains technically favorable PG cases, introducing selection bias that complicates direct comparison between reconstructions. In the study, no significant difference was ultimately found between the two groups in POPF rates (overall and in high-risk individuals). Similarly, no differences were observed in rates of PPH, CRPF, biliary leaks, DGE, overall mortality, or LoS.

At the same time, the trial was characterized by higher-than-expected pancreatectomy-related complication rates (CRPF, PPH, biliary leaks) across both reconstruction arms. Beyond CRPF, the relatively elevated rates of PPH, biliary fistula, and DGE, in comparison to other published RCTs (45), that were observed after surgery suggest a substantial overall morbidity burden in the study population. These findings are particularly relevant when considered alongside the study’s original superiority design, which assumed a large absolute reduction (about 15 percentage points) in CRPF between techniques. Such effect-size assumptions appear misaligned with the randomized trials and the meta-analyses cited by the authors themselves and may have predisposed the study to inadequate statistical power. Together with the observed rates of biliary fistula, early hemorrhage, and DGE—each exceeding what is commonly reported in contemporary high-volume settings—these findings raise broader questions regarding the interpretation, and generalizability of the trial’s results. While the multicenter design of the study enhances external validity, it likely also reflects heterogeneity in peri- and intra-operative management, patient selection, and complication reporting across participating centers, further complicating attribution of outcomes to reconstructive technique alone.

This trial has also indicated a possible difference in the quality of life (QoL) over the 9 months following surgery, with PG patients showing a greater decline followed by a recovery. Importantly, inter-subject analyses at 9 months suggest that meaningful distinctions between PG and PJ may emerge in longer-term functional and symptom-related domains, rather than in traditional short-term postoperative outcomes. These findings point toward a potential divergence in how patients perceive recovery and daily functioning over time after different reconstruction strategies. Notably, these QoL differences occurred despite the absence of measurable differences in objective nutritional or pancreatic function parameters, including weight change, EPI symptoms, and pancreatic enzyme replacement therapy (PERT) use at both 3 and 9 months. This dissociation suggests that the apparent QoL advantage observed with PG at 9 months likely reflects patient-reported well-being, functional adaptation, or symptom perception, rather than overt differences in nutritional status or pancreatic exocrine output. However, as patients in the PJ group appear to have achieved higher rates of completion of adjuvant chemotherapy, the assessment of QoL may be subject to bias from adverse effects of chemotherapy over a longer period of time.

This study joins the pre-existing literature supporting the use of careful technique and clinical judgement in selecting the optimal reconstruction approach. Many other reconstruction strategies have been established and adopted over the years for PE anastomosis in addition to the modified Blumgart PJ and the invaginated PG which were evaluated in this trial. Other commonly practiced options include classic “dunking” PJ (28,30,46), multiple duct-to-mucosa PJ variants (28,47), and duct-to-mucosa PG configurations (48), all of which remain widely adopted across institutions worldwide (22). Moreover, nowadays, the choice of reconstruction is increasingly influenced by the operative approach—open versus minimally invasive—which may impose different technical constraints and learning curves and further shape surgeon preference and technique selection (49,50). The coexistence of numerous well-recognized techniques highlights the heterogeneity of current practice and the persistent uncertainty regarding whether specific variants may offer advantages in particular anatomical or institutional contexts. With this broader landscape in mind, and recognizing that the conclusions of the present trial pertain exclusively to the two techniques studied rather than to PJ or PG as broad categories, it appears as though no clear differences exist between invaginating PG and modified Blumgart PJ reconstructions, and it is the surgeon’s preference, familiarity with multiple techniques, and clinical judgement, based on anatomical and physiological patient factors, that should drive the decision-making.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-508/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-508/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bruna CL, Emmen AMLH, Wei K, et al. Effects of Pancreatic Fistula After Minimally Invasive and Open Pancreatoduodenectomy. JAMA Surg 2025;160:190-8. [Crossref] [PubMed]
2. Casciani F, Bassi C, Vollmer CM Jr. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021;170:889-909. [Crossref] [PubMed]
3. Mirrielees JA, Weber SM, Abbott DE, et al. Pancreatic Fistula and Delayed Gastric Emptying Are the Highest-Impact Complications After Whipple. J Surg Res 2020;250:80-7. [Crossref] [PubMed]
4. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;161:584-91. [Crossref] [PubMed]
5. Kawaida H, Kono H, Hosomura N, et al. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol 2019;25:3722-37. [Crossref] [PubMed]
6. Smits FJ, Verweij ME, Daamen LA, et al. Impact of Complications After Pancreatoduodenectomy on Mortality, Organ Failure, Hospital Stay, and Readmission: Analysis of a Nationwide Audit. Ann Surg 2022;275:e222-8. [Crossref] [PubMed]
7. Pulvirenti A, Marchegiani G, Pea A, et al. Clinical Implications of the 2016 International Study Group on Pancreatic Surgery Definition and Grading of Postoperative Pancreatic Fistula on 775 Consecutive Pancreatic Resections. Ann Surg 2018;268:1069-75. [Crossref] [PubMed]
8. Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore) 2017;96:e6858. [Crossref] [PubMed]
9. Bonaroti JW, Zenati MS, Al-Abbas AI, et al. Impact of postoperative pancreatic fistula on long-term oncologic outcomes after pancreatic resection. HPB (Oxford) 2021;23:1269-76. [Crossref] [PubMed]
10. Zhang B, Yuan Q, Li S, et al. Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis. Medicine (Baltimore) 2022;101:e29757. [Crossref] [PubMed]
11. Schouten TJ, Henry AC, Smits FJ, et al. Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort. Ann Surg 2023;278:1001-8. [Crossref] [PubMed]
12. Hu BY, Wan T, Zhang WZ, et al. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol 2016;22:7797-805. [Crossref] [PubMed]
13. Hartwig W, Werner J, Jäger D, et al. Improvement of surgical results for pancreatic cancer. Lancet Oncol 2013;14:e476-85. [Crossref] [PubMed]
14. PARANOIA Study Group. Perioperative interventions to reduce pancreatic fistula following pancreatoduodenectomy: meta-analysis. Br J Surg 2022;109:812-21. [Crossref] [PubMed]
15. Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016;51:1147-54. [Crossref] [PubMed]
16. Schuh F, Mihaljevic AL, Probst P, et al. A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 2023;277:e597-608. [Crossref] [PubMed]
17. Brunner M, Kovacevic J, Krautz C, et al. Analysis of Intraoperative Frozen Pancreatic Resection Margin and Prediction of Postoperative Pancreatic Fistula Risk During Pancreatoduodenectomy. J Am Coll Surg 2022;234:928-37. [Crossref] [PubMed]
18. Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery 2010;148:15-23. [Crossref] [PubMed]
19. Schuh F, Yildirim B, Klotz R, et al. Prospective Validation of the Pancreatic Fistula Risk Classification by the International Study Group for Pancreatic Surgery (PARIS trial). Ann Surg 2024; Epub ahead of print. [Crossref]
20. Torphy R, Ho F, Shulick R. Management of Acute Complications in Pancreatic Surgery. In: Gastrointestinal Surgical Emergencies. Chicago (IL): American College of Surgeons; 2021.
21. Roh YH, Kang BK, Song SY, et al. Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy. PLoS One 2020;15:e0243515. [Crossref] [PubMed]
22. Shrikhande SV, Sivasanker M, Vollmer CM, et al. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2017;161:1221-34. [Crossref] [PubMed]
23. Kawaida H, Kono H, Amemiya H, et al. Anastomosis technique for pancreatojejunostomy and early removal of drainage tubes may reduce postoperative pancreatic fistula. World J Surg Oncol 2020;18:295. [Crossref] [PubMed]
24. Cheng Y, Briarava M, Lai M, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2017;9:CD012257. [Crossref] [PubMed]
25. Keck T, Wellner UF, Bahra M, et al. Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial. Ann Surg 2016;263:440-9. [Crossref] [PubMed]
26. Topal B, Fieuws S, Aerts R, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol 2013;14:655-62. [Crossref] [PubMed]
27. Andrianello S, Marchegiani G, Malleo G, et al. Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis: A Single-Center, Phase 3, Randomized Clinical Trial. JAMA Surg 2020;155:313-21. [Crossref] [PubMed]
28. Wu X, Hu L, Zhou S, et al. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2025;10:CD013462. [Crossref] [PubMed]
29. Salman MA, Elewa A, Elsherbiny M, et al. Postoperative pancreatic fistula after pancreaticogastrostomy versus pancreatojejunostomy after pancreatic resection, a comparative systematic review and meta-analysis. World J Surg 2024;48:1467-80. [Crossref] [PubMed]
30. Hao X, Li Y, Liu L, et al. Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials. Heliyon 2024;10:e33156. [Crossref] [PubMed]
31. Cao Z, Luo W, Qiu J, et al. Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis. Front Oncol 2020;10:1637. [Crossref] [PubMed]
32. Cao F, Tong X, Li A, et al. Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy. Asian J Surg 2020;43:1056-61. [Crossref] [PubMed]
33. Li Z, Wei A, Xia N, et al. Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis. Sci Rep 2020;10:17896. [Crossref] [PubMed]
34. Menahem B, Guittet L, Mulliri A, et al. Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Ann Surg 2015;261:882-7. [Crossref] [PubMed]
35. Timmermann L, Bahra M, Pratschke J, et al. Development of a Novel Dorsal Incision Only Invagination Type Pancreatogastrostomy (Charité-PG) Following Open Pancreaticoduodenectomy-A Single Centre Experience. J Clin Med 2021;10:2573. [Crossref] [PubMed]
36. Casadei R, Ricci C, Ingaldi C, et al. Comparison of Blumgart Anastomosis with Duct-to-Mucosa Anastomosis and Invagination Pancreaticojejunostomy After Pancreaticoduodenectomy: A Single-Center Propensity Score Matching Analysis. J Gastrointest Surg 2021;25:411-20. [Crossref] [PubMed]
37. Halkic N, Kobayashi K, Kokudo T, et al. Pancreaticogastrostomy after pancreaticoduodenectomy without suturing the pancreas. Surg Today 2020;50:200-4. [Crossref] [PubMed]
38. Li YT, Zhang HY, Xing C, et al. Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy. World J Gastroenterol 2019;25:2514-23. [Crossref] [PubMed]
39. Ma S, Li Q, Dai W, et al. Pancreaticogastrostomy versus pancreaticojejunostomy. J Surg Res 2014;192:68-75. [Crossref] [PubMed]
40. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009;208:738-47; discussion 747-9. [Crossref] [PubMed]
41. Kleespies A, Rentsch M, Seeliger H, et al. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg 2009;96:741-50. [Crossref] [PubMed]
42. Standop J, Overhaus M, Schaefer N, et al. Pancreatogastrostomy after pancreatoduodenectomy: a safe, feasible reconstruction method? World J Surg 2005;29:505-12. [Crossref] [PubMed]
43. Sposito C, Mazzola M, Pezzoli I, et al. Pancreaticojejunostomy Versus Neoprene-based Pancreatic Duct Occlusion in Pancreaticoduodenectomy for Patients at Intermediate-high Risk of Post-operative Pancreatic Fistula: A Comparative Cohort Study. Ann Surg 2025; Epub ahead of print. [Crossref]
44. Dorcaratto D, Garcés-Albir M, Palomares-Casasús S, et al. Blumgart Anastomosis Versus Invaginating Pancreatogastrostomy for Reconstruction after Pancreatoduodenectomy: A Randomized Controlled Trial. Ann Surg 2025;282:699-708. [Crossref] [PubMed]
45. Lavu H, McCall NS, Winter JM, et al. Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway. J Am Coll Surg 2019;228:415-24. [Crossref] [PubMed]
46. Gaitanidis A, Lo WM, Burke RA, et al. Pancreaticojejunostomy with duct-to-mucosa versus invagination techniques: a propensity-score matching analysis based on pancreatic duct size and gland texture. Am J Surg 2025;250:116646. [Crossref] [PubMed]
47. Casadei R, Ricci C, Ingaldi C, et al. Comparison of Blumgart Anastomosis with Duct-to-Mucosa Anastomosis and Invagination Pancreaticojejunostomy After Pancreaticoduodenectomy: A Single-Center Propensity Score Matching Analysis. J Gastrointest Surg 2021;25:411-20. [Crossref] [PubMed]
48. Petrova E, Suurmeijer JA, Mackay TM, et al. Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits. Surgery 2021;170:1799-806. [Crossref] [PubMed]
49. Barberio M, Milizia A, Pizzicannella M, et al. End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience. Surg Endosc 2023;37:7370-5. [Crossref] [PubMed]
50. De Pastena M, Bannone E, Andreotti E, et al. Pancreatic Anastomosis in Robotic-Assisted Pancreaticoduodenectomy: Different Surgical Techniques. Dig Surg 2023;40:1-8. [Crossref] [PubMed]