Journal of Gastrointestinal Surgery

, Volume 18, Issue 9, pp 1693–1704 | Cite as

Pancreaticogastrostomy Versus Pancreaticojejunostomy After Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

  • Michael Clerveus
  • Antonio Morandeira-Rivas
  • Joaquín Picazo-Yeste
  • Carlos Moreno-Sanz
Review Article



The aim of this systematic review was to compare postoperative outcomes between pancreaticogastrostomy and pancreaticojejunostomy after pancreaticoduodenectomy.


Six databases were systematically reviewed to identify randomized controlled trials comparing pancreaticogastrostomy and pancreaticojejunostomy. Studies reporting postoperative complications, reoperations, and mortality were included (PROSPERO registration number CRD42013005383).


The search provided a total of 1,646 references. Seven studies were selected including 1,121 patients, 562 in the pancreaticogastrostomy group and 559 in the pancreaticojejunostomy group. Overall incidence of pancreatic fistula and the incidence of more severe fistulas (grade B/C) were lower in the pancreaticogastrostomy group (relative risk 0.67; 95 % confidence interval (CI) 0.52 to 0.86; p = 0.002 and relative risk 0.61; 95 % CI 0.40 to 0.93; p = 0.02). Abdominal collections were more frequent in the pancreaticojejunostomy group. However, pancreaticogastrostomy was associated with an increased risk of postoperative intraluminal hemorrhage, and there were no differences in overall morbidity, reoperations, or mortality.


In this systematic review and meta-analysis, a reduction in the incidence of postoperative pancreatic fistula in the pancreaticogastrostomy group was observed. Although this evidence comes from randomized trials, pancreaticogastrostomy cannot be considered superior to pancreaticojejunostomy due to the presence of clinical heterogeneity among studies and the absence of differences in overall morbidity, reoperations, and mortality.


Pancreaticogastrostomy Pancreaticojejunostomy Pancreatic fistula Pancreaticoduodenectomy 



The authors would like to thank the staff of the Research Support Unit at the Mancha Centro General Hospital for their valuable comments and suggestions.

Conflict of Interest

Nothing to disclose.


  1. 1.
    Addeo P, Delpero JR, Paye F, Oussoultzoglou E, Fuchshuber PR, Sauvanet A, Sa Cunha A, Le Treut YP, Adham M, Mabrut JY, Chiche L, Bachellier P. Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association. HPB 2014;16:46–55.CrossRefPubMedGoogle Scholar
  2. 2.
    Muscari F, Suc B, Kirzin S, Hay JM, Fourtanier G, Fingerhut A, Sastre B, Chipponi J, Fagniez PL, Radovanovic A. Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery 2006;139:591–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, Hodgin MB, Sauter PK, Hruban RH, Riall TS, Schulick RD, Choti MA, Lillemoe KD, Yeo CJ. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 2006;10:1199–210.CrossRefPubMedGoogle Scholar
  4. 4.
    Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997;226:248–57.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Schafer M, Mullhaupt B, Clavien PA. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 2002;236:137–48.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, Gumbs A, Pederzoli P. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 2004;21:54–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg 2008;32:419–28.CrossRefPubMedGoogle Scholar
  8. 8.
    Wellner UF, Kayser G, Lapshyn H, Sick O, Makowiec F, Hoppner J, Hopt UT, Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB 2010;12:696–702.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Hashimoto D, Chikamoto A, Ohmuraya M, Hirota M, Baba H. Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy. Surg Today 2013 Jul 13;[Epub ahead of print].Google Scholar
  10. 10.
    Lai EC, Lau SH, Lau WY. Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 2009;144:1074–80.CrossRefPubMedGoogle Scholar
  11. 11.
    Reid-Lombardo KM, Farnell MB, Crippa S, Barnett M, Maupin G, Bassi C, Traverso LW. Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1,507 patients: a report from the Pancreatic Anastomotic Leak Study Group. J Gastrointest Surg 2007;11:1451–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Watanabe M, Usui S, Kajiwara H, Nakamura M, Sumiyama Y, Takada T, Nagakawa T. Current pancreatogastrointestinal anastomotic methods: results of a Japanese survey of 3109 patients. J Hepatobiliary Pancreat Surg 2004;11:25–33.CrossRefPubMedGoogle Scholar
  13. 13.
    Aranha GV, Hodul P, Golts E, Oh D, Pickleman J, Creech S. A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy. J Gastrointest Surg 2003;7:672–82.CrossRefPubMedGoogle Scholar
  14. 14.
    Schlitt HJ, Schmidt U, Simunec D, Jager M, Aselmann H, Neipp M, Piso P. Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy. Br J Surg 2002;89:1245–51.CrossRefPubMedGoogle Scholar
  15. 15.
    Oussoultzoglou E, Bachellier P, Bigourdan JM, Weber JC, Nakano H, Jaeck D. Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 2004;139:327–35.CrossRefPubMedGoogle Scholar
  16. 16.
    McKay A, Mackenzie S, Sutherland FR, Bathe OF, Doig C, Dort J, Vollmer CM, Jr., Dixon E. Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 2006;93:929–36.CrossRefPubMedGoogle Scholar
  17. 17.
    Wente MN, Shrikhande SV, Muller MW, Diener MK, Seiler CM, Friess H, Buchler MW. Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg 2007;193:171–83.CrossRefPubMedGoogle Scholar
  18. 18.
    He T, Zhao Y, Chen Q, Wang X, Lin H, Han W. Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. Dig Surg 2013;30:56–69.CrossRefPubMedGoogle Scholar
  19. 19.
    Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, Mantovani W, Pederzoli P. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 2005;242:767–71.PubMedCentralCrossRefPubMedGoogle Scholar
  20. 20.
    Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580–8.PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, Fingerhut A, Millat B, Radovanowic A, Fagniez PL. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 2005;189:720–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Fernandez-Cruz L, Cosa R, Blanco L, Lopez-Boado MA, Astudillo E. Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study. Ann Surg 2008;248:930–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Yang SH, Dou KF, Sharma N, Song WJ. The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg 2011;35:2290–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Ma JP, Peng L, Qin T, Lin JW, Chen CQ, Cai SR, Wang L, He YL. Meta-analysis of pancreaticoduodenectomy prospective controlled trials: pancreaticogastrostomy versus pancreaticojejunostomy reconstruction. Chin Med J (Engl) 2012;125:3891–7.Google Scholar
  25. 25.
    Shen Y, Jin W. Reconstruction by pancreaticogastrostomy versus pancreaticojejunostomy following pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. Gastroenterol Res Pract 2012;2012:627095.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Figueras J, Sabater L, Planellas P, Munoz-Forner E, Lopez-Ben S, Falgueras L, Sala-Palau C, Albiol M, Ortega-Serrano J, Castro-Gutierrez E. Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy. Br J Surg 2013;100:1597–605.CrossRefPubMedGoogle Scholar
  27. 27.
    Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hubert C, Janssens M, Closset J. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol 2013;14:655–62.CrossRefPubMedGoogle Scholar
  28. 28.
    Wellner UF, Sick O, Olschewski M, Adam U, Hopt UT, Keck T. Randomized controlled single-center trial comparing pancreatogastrostomy versus pancreaticojejunostomy after partial pancreatoduodenectomy. J Gastrointest Surg 2012;16:1686–95.CrossRefPubMedGoogle Scholar
  29. 29.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6:e1000100.PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13.CrossRefPubMedGoogle Scholar
  31. 31.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13.PubMedCentralCrossRefPubMedGoogle Scholar
  32. 32.
    DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931–7.PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions Version 5.1.0. Oxford, UK: The Cochrane Collaboration; 2011.Google Scholar
  34. 34.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539–58.CrossRefPubMedGoogle Scholar
  35. 35.
    Keck T, Wellner U, Makowiec F, Hopt U. Pancreatogastrostomy or pancreaticojejunostomy after pancreatoduodenectomy-single-center prospective randomized trial. HPB 2010;12:19–20.Google Scholar
  36. 36.
    Wellner UF, Sick O, Makowiec F, Hopt UT, Keck T. Pancreatogastrostomy versus pancreaticojejunostomy-results of a single center randomized trial. Langenbeck’s Archives of Surgery 2011;396:880.Google Scholar
  37. 37.
    Radenkovic D, Bajec D, Gregoric P, Ivancevic N, Jeremic V, Karadzic B, Antic A, Pejovic I, Kmezic S. Background and design of multicenter randomized study: pancreaticojejunostomy versus pancreaticogastrostomy in patients with soft residual pancreas and small diameter of pancreatic duct. Pancreatology 2013;13:e67.CrossRefGoogle Scholar
  38. 38.
    Wellner UF, Brett S, Bruckner T, Limprecht R, Rossion I, Seiler C, Sick O, Wegener I, Hopt UT, Keck T. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after partial PANCreatoduodenectomy (RECOPANC): study protocol of a randomized controlled trial UTN U1111-1117-9588. Trials 2012;13:45.PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Radenkovic D, Bajec DJ, Ivancevic N, Gregoric P, Jeremic V, Djuki V, Kardzic DB, Antic A, Pejovic I. Results of pancreatogastrostomy versus pancreaticojejunostomy in reconstruction after cephalic duodenopancreatectomy in patients with soft pancreas and small pancreatic DUCT-PANAM study. Pancreas 2011;40:1350.Google Scholar
  40. 40.
    Mansoura University. Isolated roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy (PD). In: [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2013 Dic 1]. Available from: NLM Identifier: NCT01859806.
  41. 41.
    University of Calgary. Reconstruction following pancreaticoduodenectomy: a randomized clinical trial of pancreaticojejunostomy vs pancreaticogastomy In: [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2013 Dic 1]. Available from: NCT00841607 NLM Identifier: NCT00841607.
  42. 42.
    Valle RD, De’Angelis N. Two layer open pancreaticogastrostomy. Toward an easy and safe anastomosis? Preliminary experience. HPB 2011;13:108.Google Scholar
  43. 43.
    Ramesh H, Kundil B, Venugopal A, Venugopal B, Bedi MMS, Lekha V, Jacob M, Sharma M, Mahesh S. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction after whipple operation for malignancy: interim results of a randomized controlled trial. Pancreas 2009;38:1040.Google Scholar
  44. 44.
    Konishi M, Ryu M, Kinoshita T, Inoue K. Pathophysiology after pylorus-preserving pancreatoduodenectomy: a comparative study of pancreatogastrostomy and pancreatojejunostomy. Hepatogastroenterology 1999;46:1181–6.PubMedGoogle Scholar
  45. 45.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Riediger H, Makowiec F, Schareck WD, Hopt UT, Adam U. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications. J Gastrointest Surg 2003;7:758–65.CrossRefPubMedGoogle Scholar
  47. 47.
    Murakami Y, Uemura K, Hayashidani Y, Sudo T, Hashimoto Y, Ohge H, Sueda T. Long-term pancreatic endocrine function following pancreatoduodenectomy with pancreaticogastrostomy. J Surg Oncol 2008;97:519–22.CrossRefPubMedGoogle Scholar
  48. 48.
    Ishikawa O, Ohigashi H, Eguchi H, Yokoyama S, Yamada T, Takachi K, Miyashiro I, Murata K, Doki Y, Sasaki Y, Imaoka S. Long-term follow-up of glucose tolerance function after pancreaticoduodenectomy: comparison between pancreaticogastrostomy and pancreaticojejunostomy. Surgery 2004;136:617–23.CrossRefPubMedGoogle Scholar
  49. 49.
    Takada T, Yasuda H, Uchiyama K, Hasegawa H, Misu Y, Iwagaki T. Pancreatic enzyme activity after a pylorus-preserving pancreaticoduodenectomy reconstructed with pancreaticogastrostomy. Pancreas 1995;11:276–82.CrossRefPubMedGoogle Scholar
  50. 50.
    Jang JY, Kim SW, Park SJ, Park YH. Comparison of the functional outcome after pylorus-preserving pancreatoduodenectomy: pancreatogastrostomy and pancreatojejunostomy. World J Surg 2002;26:366–71.CrossRefPubMedGoogle Scholar
  51. 51.
    Schmidt U, Simunec D, Piso P, Klempnauer J, Schlitt HJ. Quality of life and functional long-term outcome after partial pancreatoduodenectomy: pancreatogastrostomy versus pancreatojejunostomy. Ann Surg Oncol 2005;12:467–72.CrossRefPubMedGoogle Scholar
  52. 52.
    Rault A, SaCunha A, Klopfenstein D, Larroude D, Epoy FN, Collet D, Masson B. Pancreaticojejunal anastomosis is preferable to pancreaticogastrostomy after pancreaticoduodenectomy for longterm outcomes of pancreatic exocrine function. J Am Coll Surg 2005;201:239–44.CrossRefPubMedGoogle Scholar
  53. 53.
    Lemaire E, O'Toole D, Sauvanet A, Hammel P, Belghiti J, Ruszniewski P. Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis. Br J Surg 2000;87:434–8.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2014

Authors and Affiliations

  • Michael Clerveus
    • 1
  • Antonio Morandeira-Rivas
    • 1
  • Joaquín Picazo-Yeste
    • 1
  • Carlos Moreno-Sanz
    • 1
  1. 1.Department of Surgery“Mancha Centro” General HospitalCiudad RealSpain

Personalised recommendations