Design: Randomised, open-label trial at two high-volume centres
Population: 158 adults undergoing pancreatoduodenectomy
Primary outcome: Delayed gastric emptying within 90 days
Effect: 38.0% side-to-side vs 30.4% end-to-side; RR 1.25 (95% CI 0.81 to 1.94)

Delayed gastric emptying is one of the commonest complications after pancreatoduodenectomy, and retrospective series had suggested that a side-to-side gastrojejunostomy might reduce it. The IPAD trial tested this at two high-volume French centres, randomising 158 patients during surgery to side-to-side or end-to-side configuration and following them for 90 days.

Delayed gastric emptying occurred in 38.0% after side-to-side and 30.4% after end-to-side anastomosis (RR 1.25, 95% CI 0.81 to 1.94). Pancreatic and biliary fistula, reintervention, mortality, nutrition and quality of life at 90 days were similar.

The trial was open-label and modest in size, and the point estimate leaned slightly against side-to-side. It does not support changing technique to prevent delayed emptying.

Surgeons can keep the configuration they are most practised in, and look to other factors, such as fistula prevention and early feeding, to reduce delayed gastric emptying.

There is no need to switch to side-to-side gastrojejunostomy to prevent delayed gastric emptying
Use the configuration you perform most reliably
Expect delayed gastric emptying in about a third of patients after pancreatoduodenectomy and plan nutrition for it
Pancreatic fistula and intra-abdominal collections drive much secondary delayed emptying; look for them

Why it matters

It removes a technical debate that retrospective series had kept alive.

The statistics, in plain English

A risk ratio of 1.25 with a confidence interval of 0.81 to 1.94 crosses 1.0. The trial cannot rule out a modest difference either way, but it gives no support to the claim that side-to-side is better.