Critical Appraisal of Pancreaticogastrostomy After Pancreatoduodenectomy: Evolution, Evidence, and Future Prospects

Pancreaticogastrostomy (PG) emerged as a reconstructive option after pancreaticoduodenectomy (PD) due to its reported lower incidence of postoperative pancreatic fistula (POPF), but its superiority over pancreaticojejunostomy (PJ) remains unclear. We provide a narrative review that summarizes its evolution, technical variations, and comparative outcomes versus PJ. A narrative review from a comprehensive literature search was conducted using electronic databases of Medline/PubMed, EMBASE, and the Cochrane Library to identify relevant studies addressing surgical techniques, outcomes, and comparative analyses. PG offers anatomical, physiological advantages, including tension-free anastomosis and gastric acid inactivation of pancreatic enzymes. Early RCTs showed similar clinically relevant POPF rates. Later trials supported PG for soft glands and small ducts, showing fewer intraperitoneal collections but more hemorrhage. Despite similar short-term outcomes, long-term randomized follow-up shows worse exocrine function after PG than PJ, with higher fecal fat, lower fecal elastase-1, and greater pancreatic atrophy. PG is an effective reconstruction option after PD, particularly in POPF high-risk cases. However, it has higher bleeding rates and worse long-term exocrine function than PJ. Reconstruction should prioritize pancreatic function, favoring PJ for most patients and reserving PG for selected soft, small-duct, or high-risk glands based on institutional expertise.