Pancreaticoduodenectomy is a complex procedure to treat pancreatic and periampullary neoplasms, as well as particular forms of chronic pancreatitis. The pancreatic remnant is sutured either with the jejunum (pancreaticojejunostomy) or the stomach (pancreaticogastrostomy) to allow the normal outflow of pancreatic juice. 

The surgical community has seen intense debate about what is the best reconstruction method to reduce the burden of fistula after pancreaticoduodenectomy. Pancreaticojejunostomy is the most widely performed reconstruction, but pancreaticogastrostomy has become more popular and has been assessed in various studies over the past 10 years. 

One of the randomized clinical trials of pancreaticojejunostomy versus pancreaticogastrostomy was concucted in Verona in 2005, and did not show any difference between the two techniques. In a new nationwide, multicentre randomized superiority trial comparing these two reconstruction methods, Topal et al. have shown that pancreaticogastrostomy leads to fewer patients experiencing postoperative pancreatic fistulas than pancreaticojejunostomy (Topal et al, Lancet Oncol 2013;14:655-662).

The debate remains open. Prof. Bassi and Dr. Malleo discussed this issue on the journal Nature Reviews Gastroenterology and Hepatology, and suggested that both the pancreatic surgeons should be confident with both the techniques. The choice of which reconstruction method to adopt after pancreaticoduodenectomy should be based not only on the risk of postoperative pancreatic fistula, but also on the underlying disease, life expectancy and long‑term quality of life.