What are the benefits and risks of bowel reconstruction routes after partial surgical removal of the pancreas and duodenum (first part of the small intestine)?

Key messages

- Antecolic bowel reconstruction may not reduce delayed gastric emptying after partial surgical removal of the pancreatic head and duodenum.

- Our results do not suggest any relevant differences between both techniques in other morbidity, mortality, length of hospital stay, and quality of life.


The pancreas is a digestive gland situated in the upper abdomen, which is also vital to normal control of blood sugar. Pancreatic cancer is one of the leading causes of cancer death in industrialised nations. The standard surgical treatment for cancer of the head of the gland and precancerous abnormalities is partial removal of the pancreas, together with the attached duodenum, known as a pancreaticoduodenectomy. Removal of the duodenum requires the restoration of the digestive pathway from the stomach to the rest of the gut. This can be accomplished by joining it to the jejunum (second part of the small intestine) either in front of (antecolic) or behind (retrocolic) the overlying large intestine (transverse colon).

What did we want to find out?

We wanted to find out whether one of the above-mentioned two routes of reconstruction provides a benefit to the patient by reducing delayed gastric emptying (emptying of the stomach after ingestion of food); postoperative mortality (death); and other complications, such as pancreatic fistula (leakage of pancreatic juice), reoperation, perioperative measures (before, during, and after the operation), or length of hospital stay; and improving quality of life. Delayed gastric emptying was the primary outcome of this review because it is one of the most frequent complications after a pancreaticoduodenectomy; it can make it difficult to take anything by mouth and interferes with the patient’s quality of life, often resulting in a prolonged hospital stay and delay of further treatment.

What did we do?

We searched for studies that compared antecolic with retrocolic reconstruction in patients undergoing partial removal of the pancreas together with the duodenum. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We included eight randomised controlled trials (reported in 11 publications), reporting data on a total of 818 adult participants, who underwent pancreaticoduodenectomy for any pancreatic disease.

Main results

We did not identify relevant differences in delayed gastric emptying; postoperative mortality; postoperative pancreatic fistula, or other complications; reoperations; or length of hospital stay. Quality of life, only reported for a subset of participants in one trial, did not differ between the two groups. Our results do not suggest any relevant differences between antecolic and retrocolic reconstruction of the gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.

What are the limitations of the evidence?

Our confidence in the results is limited because the results from the studies varied widely, and most studies involved only small numbers of people. Most studies used methods likely to introduce errors. Therefore, the results should be interpreted in the light of these limitations.

How up to date is this evidence?

This review updates our previous review. The evidence is current to July 2021.

Authors' conclusions: 

There was low- to moderate-certainty evidence suggesting that antecolic reconstruction after partial pancreaticoduodenectomy results in little to no difference in morbidity, mortality, length of hospital stay, or quality of life. Due to heterogeneity in definitions of the endpoints between trials, and differences in postoperative management, future research should be based on clearly defined endpoints and standardised perioperative management, to potentially elucidate differences between these two procedures. Novel strategies should be evaluated for prophylaxis and treatment of common complications, such as delayed gastric emptying.

Read the full abstract...

Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialised nations. For adenocarcinomas in the head of the gland and premalignant lesions, partial pancreaticoduodenectomy represents the standard treatment for resectable tumours. The gastro- or duodenojejunostomy after partial pancreaticoduodenectomy can be reestablished via either an antecolic or retrocolic route. The debate about the more favourable technique for bowel reconstruction is ongoing.


To compare the effectiveness and safety of antecolic and retrocolic gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.

Search strategy: 

In this updated version, we conducted a systematic literature search up to 6 July 2021 to identify all randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library 2021, Issue 6, MEDLINE (1946 to 6 July 2021), and Embase (1974 to 6 July 2021). We applied no language restrictions. We handsearched reference lists of identified trials to identify further relevant trials, and searched the trial registries clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform for ongoing trials.

Selection criteria: 

We considered all RCTs comparing antecolic with retrocolic reconstruction of bowel continuity after partial pancreaticoduodenectomy for any given indication to be eligible.

Data collection and analysis: 

Two review authors independently screened the identified references and extracted data from the included trials. The same two review authors independently assessed risk of bias of included trials, according to standard Cochrane methodology. We used a random-effects model to pool the results of the individual trials in a meta-analysis. We used odds ratios (OR) to compare binary outcomes and mean differences (MD) for continuous outcomes.

Main results: 

Of a total of 287 citations identified by the systematic literature search, we included eight randomised controlled trials (reported in 11 publications), with a total of 818 participants. There was high risk of bias in all of the trials in regard to blinding of participants and/or outcome assessors and unclear risk for selective reporting in six of the trials.

There was little or no difference in the frequency of delayed gastric emptying (OR 0.67; 95% confidence interval (CI) 0.41 to 1.09; eight trials, 818 participants, low-certainty evidence) with relevant heterogeneity between trials (I2=40%).

There was little or no difference in postoperative mortality (risk difference (RD) -0.00; 95% CI -0.02 to 0.01; eight trials, 818 participants, high-certainty evidence); postoperative pancreatic fistula (OR 1.01; 95% CI 0.73 to 1.40; eight trials, 818 participants, low-certainty evidence); postoperative haemorrhage (OR 0.87; 95% CI 0.47 to 1.59; six trials, 742 participants, low-certainty evidence); intra-abdominal abscess (OR 1.11; 95% CI 0.71 to 1.74; seven trials, 788 participants, low-certainty evidence); bile leakage (OR 0.82; 95% CI 0.35 to 1.91; seven trials, 606 participants, low-certainty evidence); reoperation rate (OR 0.68; 95% CI 0.34 to 1.36; five trials, 682 participants, low-certainty evidence); and length of hospital stay (MD -0.21; 95% CI -1.41 to 0.99; eight trials, 818 participants, low-certainty evidence).

Only one trial reported quality of life, on a subgroup of 73 participants, also without a relevant difference between the two groups at any time point. The overall certainty of the evidence was low to moderate, due to some degree of heterogeneity, inconsistency and risk of bias in the included trials.