Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy

Background: Pancreaticogastrostomy (PG) after pancreaticoduodenectomy has been reported to have a lower incidence of pancreatic fistula than pancreaticojejunostomy (PJ) but this was not confirmed in a recent prospective randomized study. Methods: Different methods of reconstruction after pancreaticoduodenectomy were used between January 1994 and January 1999 in two university-affiliated hospitals, PJ (n = 69) in one hospital and PG (n = 73) in the other. Operations at both hospitals were performed by the same surgical team. All pancreatic anastomoses were carried out in two layers with pancreatic duct stents. Pancreatic fistula was identified by the presence of more than 1000 units/l of amylase-rich fluid in the drains 7 days or more after operation, by radiography from the pancreatic duct stent and by water-soluble contrast upper gastrointestinal studies. Results: The two groups of patients were similar in terms of age, sex, findings at preoperative assessment, disease status, operative time, intraoperative blood loss and nature of non-tumorous pancreatic tissue. The amylase level in ascites at 7 days after operation was significantly lower after PG than PJ (P = 0.032). The incidence of pancreatic fistula in the PG group (zero) was significantly less than that after PJ (13 per cent) (P = 0.014). Intra-abdominal haemorrhage and intra-abdominal abscess occurred in three (4 per cent) and four patients (6 per cent) respectively, with two hospital deaths (3 per cent) in the PJ group, but these complications did not occur after PG. Conclusion: This controlled clinical study supports the hypothesis that PG is safer than PJ, particularly with regard to the incidence of pancreatic fistula.