Understanding pancreatic reconstruction after pancreatoduodenectomy: lessons in technique and biology

Pancreaticoduodenectomy (PD) remains a crucial technique for management of operable diseases of the pancreatic head, duodenum, and periampullary region. Despite advances in surgical technique and perioperative care, this technically demanding operation continues to be associated with substantial postoperative morbidity, with complication rates approaching 50% (1,2). Among these, clinically relevant postoperative pancreatic fistula (CR-POPF) represents one of the most frequent and consequential complications following PD. CR-POPF can lead to intra-abdominal infection, sepsis, and the need for additional interventions. These complications can delay, or even prohibit, initiation of adjuvant treatment and thereby adversely impact oncologic outcomes (3). Considerable effort has been devoted to identifying POPF risk factors and strategies to mitigate POPF occurrence and severity (4). Several non-modifiable factors, including pancreatic duct diameter, underlying pancreatic pathology, and gland texture, have been consistently linked to POPF development. A recent meta-analysis demonstrated that soft pancreatic texture and duct diameter <3 mm were independently associated with increased risks of clinically relevant POPF [odds ratio (OR) 4.24 and 3.66, respectively] (5). Among modifiable factors, surgical technique is thought to have significant impact on POPF risk, with particular focus on different techniques for pancreatiocenteric reconstruction. However, despite decades of technical refinement, POPF remains prevalent, raising a fundamental question in pancreatic reconstructive surgery: to what extent are outcomes driven by operative technique versus intrinsic patient and pancreatic gland biology? This persistent uncertainty has led to ongoing comparisons of established reconstructive approaches with modifiable technical aspects at the time of reconstruction.

Multiple techniques exist for construction of the pancreaticoenteric anastomosis, most commonly the pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ). Within each approach, technical variations include duct-to-mucosa anastomosis with or without an invagination component. Although PJ remains the most widely adopted reconstructive technique following PD, PG continues to be evaluated because it may offer advantages in selected clinical scenarios. In particular, PG has been proposed for patients with high-risk gland characteristics, such as a soft pancreatic texture or small duct diameter, where a tension-free invagination into the stomach may reduce CR-POPF rates (6,7). Recent studies suggest that selective use of PG in high-risk patients may reduce POPF risk, although this potential benefit may be accompanied by an increased risk of postoperative hemorrhage, with overall morbidity and mortality remaining similar between the techniques (6-8). Among comparative analyses evaluating PG versus PJ techniques, there have been mixed findings regarding POPF risk. While some studies have suggested that PG may be associated with lower rates of POPF (9-11), this finding was not confirmed in a recent Cochrane systematic review of randomized trials, which demonstrated no significant difference in POPF risk between PJ and PG [risk ratio (RR) 1.19, 95% confidence interval (CI): 0.88–1.62] (12). More recently, attention has shifted toward comparisons of specific anastomotic techniques rather than conduit choice alone, with particular focus on invaginating pancreatogastrostomy (IPG) and the Blumgart anastomosis (BA). The invaginating PG involves telescoping the pancreatic stump into the stomach wall to maximize serosal tissue contact and containment of pancreatic secretions. The BA is a duct-to-mucosa PJ reinforced with transpancreatic mattress sutures to distribute tension across the pancreatic remnant. Because these techniques differ in their approaches to tension distribution, tissue perfusion, and pancreatic enzyme containment, a comparison of the two techniques provides a valuable opportunity to determine whether technical alterations can significantly impact POPF risk. Both techniques have been evaluated in randomized controlled trials and were each shown to be associated with reduced POPF risk. IPG was compared with a conventional duct-to-mucosa PJ in a randomized trial by Figueras et al., demonstrating a lower incidence of POPF (P=0.01) and reduced hospital readmission rates (P=0.005) (9). Similarly, the Blumgart technique has been compared with an interrupted-suture PJ and was associated with a reduced risk of Grade B/C POPF (OR 0.38, 95% CI: 0.22–0.65, P=0.004) (13,14). However, IPG itself has not been previously directly compared to the Blumgart PJ technique.

In a recent issue of Annals of Surgery, Dorcaratto and colleagues reported the results of a randomized controlled trial comparing the BA with invaginating PG (IPG) (15). The study included 216 patients treated across 13 high-volume centers and demonstrated no significant differences between BA and IPG in overall POPF rates (40% vs. 33%, respectively, P=0.39) or CR-POPF rates (25% vs. 23%, respectively, P=0.74). In addition, overall morbidity, severe complications, mortality, length of hospital stay, and reintervention rates were comparable between the two techniques. Patient-reported quality-of-life (QoL) measures were also similar between groups both preoperatively and at three months postoperatively.

Notably, conversion from IPG to BA due to technical difficulty occurred in 12.7% of patients assigned to the PG group, whereas no conversions from BA to PG were required. On multivariable analysis, soft pancreatic texture, smaller pancreatic duct diameter on preoperative computed tomography, advanced age, and elevated postoperative day 1 drain amylase levels were independently associated with the development of CR-POPF.

Taken together, the findings from this randomized trial are notable for directly comparing two previously validated pancreaticoenteric anastomotic techniques and demonstrating no significant differences in key postoperative outcomes, including overall POPF and CR-POPF rates. These results build upon and help reconcile prior conflicting literature. The observed conversions from IPG to BA likely reflect technical challenges in achieving a tension-free pancreaticogastric anastomosis in select patients, where adequate mobilization of the posterior wall may be limited. In such patients, the mobility of the jejunum in the BA may provide greater versatility for reconstruction. While earlier studies from the mid-2010s suggested that PG may be superior to PJ for POPF prevention (10,11), more recent data have failed to demonstrate a consistent advantage of one approach over the other (12,16,17). In particular, a Cochrane analysis of randomized controlled trials demonstrated no significant difference in the overall risk of POPF between techniques (RR 1.19, 95% CI: 0.88–1.62) (12). In comparing the BA with invaginating PG, the present study reinforces the conclusion that both techniques are feasible and comparatively safe. However, emerging risk-stratified evidence suggests that PG may offer advantages in select high-risk clinical scenarios, particularly in patients with a soft gland or small duct diameter (6,7). A PG anastomosis may facilitate a tension-free anastomosis and reduce clinically relevant POPF rates in these select patient populations. Conversely, PJ may remain preferable in lower-risk glands or in situations where gastric mobilization is limited. The findings of this study in conjunction with existing data support an individualized, risk-adapted approach to reconstruction based on patient-specific gland characteristics and intra-operative anatomy.

Importantly, the authors also address prior concerns regarding increased postoperative hemorrhage with PG (12,17-19), demonstrating no excess bleeding risk with IPG compared with BA (P=0.33) in this contemporary, multicenter cohort. In addition, this study contributes meaningfully to the limited body of literature evaluating patient-reported QoL outcomes by anastomotic technique. Although overall QoL measures were largely similar between groups, patients undergoing PG reported modestly improved quality of life at nine months postoperatively. Although overall QoL measures were largely similar between groups, patients undergoing PG demonstrated modest improvements at nine months postoperatively in functional (P=0.046) and symptom (P=0.04) domains. This finding is consistent with results from the RECOPANC trial, which similarly demonstrated improved QoL outcomes among patients undergoing PG at six and twelve months of follow-up (17). Prior studies have suggested that postoperative declines in both exocrine and endocrine pancreatic function are among the strongest determinants of patient-reported quality of life following PD (20). Because PG and PJ have been shown to impair exocrine and endocrine function to a similar extent, this likely accounts for the largely comparable overall QoL outcomes observed between patients undergoing these two reconstructive approaches (21).

Taken together, these patient-centered findings further underscore the absence of a clear superiority of one anastomotic strategy over another in contemporary practice. At the same time, they highlight the longstanding and unresolved question in pancreatic surgery about whether outcomes are driven predominantly by operative technique or intrinsic patient and gland biology. While this multicenter randomized trial provides a rigorous comparison of two well-established anastomotic techniques, its modest sample size and the observed statistically insignificant absolute difference in overall POPF rates raise the possibility that clinically meaningful differences may exist but remain undetected. Accordingly, this study does not definitively resolve the debate regarding optimal anastomotic technique but instead suggests that even technically optimized reconstructions may be constrained by intrinsic, non-modifiable biologic factors. Collectively, these findings suggest that significant reductions in morbidity and fistula rates following PD will depend on balancing technical standardization with individualized, biology-driven risk stratification. Importantly, this does not imply complete equivalence between reconstructive approaches. Instead, it raises the possibility that specific techniques may confer advantages in defined patient subgroups, such as those with high-risk gland characteristics including a soft pancreatic texture or small duct diameter. Future adequately powered randomized trials incorporating risk-stratified patient populations will be essential to determine whether tailored reconstructive strategies can improve outcomes in these high-risk cohorts. Thus, in the context of current evidence, the choice of reconstruction should be guided by surgeon experience and technical proficiency, as consistent execution of a familiar technique may be the most reliable strategy to minimize postoperative complications.

Acknowledgments

None.

Footnote

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

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Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0116/coif). The authors have no conflicts of interest to declare.

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