Received: 17 July 2017
Accepted: 13 September 2017
Pancreaticojejunostomy: Does the technique matter?
A randomized trial
Anand N. Singh MS, MCh
Sujoy Pal MS, MCh
Vivek Mangla MS, MCh
Ragini Kilambi MS, MCh
Joseph George MS, MCh
Nihar R. Dash MS
Tushar K. Chattopadhyay MS
Peush Sahni MS, PhD
Department of Gastrointestinal Surgery and
Liver Transplantation, All India Institute of
Medical Sciences, New Delhi, India
Anand N. Singh, MS, MCh, Department of
Gastrointestinal Surgery and Liver
Transplantation, All India Institute of
Medical Sciences, 1005, Teaching Block,
New Delhi -110029, India.
Background: Despite a large number of studies, the ideal technique of pancreati-
cojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We
compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a
Methods: This open-label randomized trial was done at a tertiary care center from
January 2009 to October 2015. Patients with resectable periampullary tumours with a
pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the
two techniques using computer generated random numbers. The primary outcome was
postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency
of other postoperative complications.
Results: A total of 193 patients were randomized and analyzed (intention-to-treat
analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable
for baseline demographic and clinical profiles. The incidence of POPF in the entire
study group was 23.8%. There was no statistically significant difference between the
two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C
(clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups
were comparable with respect to the secondary outcomes.
Discussion: The duct-to-mucosa technique of PJ after PD is not superior to the dunking
technique with respect to POPF rate. (CTRI/2010/091/000531)
duct-to-mucosa, dunking, invagination, pancreaticoduodenectomy, pancreaticoenteric,
pancreaticojejunostomy, pancreatoduodenectomy, whipple
The success of pancreaticoduodenectomy (PD) rests primarily on the
technical and functional outcome of the pancreaticoenteric anasto-
mosis. Pancreaticoenteric anastomotic leak contributes most to the
morbidity and mortality after PD, either directly or indirectly.
Pancreaticojejunostomy (PJ) is one of the two widely used recon-
struction techniques, pancreaticogastrostomy being the other tech-
nique. PJ has advantages such as a physiological nature, lower
incidence of post-pancreatectomy hemorrhage, lower morbidity of a
Abbreviations: DGE, delayed gastric emptying; ECOG, eastern cooperative oncology group; ISGPF, international study group for pancreatic fistula; PD, pancreaticoduodenectomy; PJ,
pancreaticojejunostomy; POPF, postoperative pancreatic fistula; PPH, post-pancreatectomy hemorrhage.
Clinical Trial Registry number: CTRI/2010/091/000531.
J Surg Oncol. 2018;117:389–396. wileyonlinelibrary.com/journal/jso © 2017 Wiley Periodicals, Inc.