Abstract
Background and Objectives: Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the two most frequently employed reconstruction techniques following pancreaticoduodenectomy (PD), yet the optimal method remains debated. The objective of this study was to compare perioperative outcomes of PG versus PJ in patients undergoing PD for resectable periampullary tumors at a high-volume center. Materials and Methods: We conducted a retrospective cohort study including 604 consecutive patients who underwent PD between January 2019 and May 2025. Reconstruction of the pancreatic remnant was achieved by binding PG in 415 patients and duct-to-mucosa PJ in 189 patients. Demographics, intraoperative data, and postoperative outcomes were analyzed using standardized ISGPS/ISGLS definitions. Results: The overall complication rate was similar between groups (43.9% vs. 47.1%; p = 0.481). However, PG was associated with significantly lower rates of postoperative pancreatic fistula (POPF) (12.3% vs. 18.5%; p = 0.042) and postoperative biliary fistula (POBF) (2.9% vs. 6.3%; p = 0.044) compared with PJ. No significant differences were observed in delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), intra-abdominal abscess, relaparotomy, length of postoperative stay, or 90-day mortality. Conclusions: PG was associated with reduced rates of anastomotic fistulas compared with PJ, while other perioperative outcomes were comparable. These findings suggest that PG may be particularly advantageous in patients with a soft pancreatic remnant or nondilated duct, where the risk of fistula is higher, whereas PJ remains appropriate for firm, fibrotic glands with dilated ducts. Tailoring the reconstructive technique to pancreatic texture and ductal anatomy may therefore improve surgical outcomes and reduce postoperative morbidity.