DGE is a common complication after PD reported in numerous studies, initially under the use of various definitions
[5, 6]. Consequently, highly differing rates of DGE were reported, which led to the introduction of the standardized definition of the ISGPS in 2007
. The proposed definition has been evaluated clinically in large patient groups after ppPD and surprisingly shown an actual overall DGE incidence of up to 45%
DGE represents a therapeutically difficult complication that prolongs patients’ hospital stay and postpones or even inhibits the start of adjuvant chemotherapy in tumor patients. Therefore, the need to reduce the frequency of DGE is obvious. In two retrospective studies a 20% reduction of DGE after prPD was shown
[9, 10]. A current randomized trial
 confirmed a reduction of DGE although the 13.7% difference between prPD and ppPD in this study was less pronounced. As the number of patients in these available studies is limited and the study designs are heterogenous, evidence is still weak and further studies are necessary to evaluate the actual impact of prPD on DGE.
It remains unclear if pylorus resection influences the severity of DGE in terms of the ISGPS grading A-C. Furthermore, no standardized therapy of DGE is defined yet, which impairs the significance of the respective results. Reconstruction technique with stenting of the pancreatic duct in the RCT
 cannot be considered as the standard reconstruction. As the overall fistula rate was rather high in this study, this could have a substantial influence on DGE. Postoperative nasogastric tube management is not standardized. From our experience, tube removal can be routinely done at the end of the general anesthesia and may also influence stomach motility in the further course.
DGE is regarded as a functional impairment of gastric motility and normal pyloric function, which has been supported by the observation that antecolic reconstruction of the duodeno-jejunal passage significantly lowered its incidence, probably due to the advantage of less chemical irritation by potential subclinical leakage of the pancreatic anastomosis within the first postoperative days. An additional anatomical modification by removing the pylorus could significantly enhance this effect. Of course, resection of the pylorus implies the risk of reflux symptoms in the long-term follow-up. Yet, this has not been proven and any long-term problems, for example gastric stump cancer after 10 to 15 years can be disregarded in pancreatic cancer patients. In patients undergoing PD for benign pathologies, however, these problems have to be taken into account and should be evaluated in long-term studies. A differential surgical approach for malignant and benign indications may be considered in case of clinically observed reflux-associated symptoms. Regarding perioperative morbidity and mortality, the available studies on prPD show comparable results underlining the feasibility of pylorus resection
In conclusion, there is increasing evidence that prPD may be associated with a decreased rate of DGE. The present study as a large randomized trial based on the currently available literature is planned to confirm these findings, which may alter surgical procedures in PD.