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Background Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy.No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication.We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction (duct-to-mucosa versus invagination),by meta-analysis and assessment of evidence quality.Methods Databases searched including The Cochrane Library,Medline,PubMed,Embase,etc.Randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination pancreaticojejunostomy were included.Outcomes of interest were pancreatic fistula rate,mortality,morbidity,reoperation and hospital stay.Pooled estimates were expressed as risk ratio (RR) or mean difference.Results From 321 identified abstracts,four RCTs (467 patients; duct-to-mucosa:232; invagination:235) were included.Pancreatic fistula rate (RR,0.74; 95％ confidence interval (Cl):0.24-2.28; P=0.60),mortality (RR,1.18; 95％ CI:0.39-3.54; P=0.77),morbidity (RR,0.91; 95％ CI:0.69-1.21; P=0.53),reoperation (RR,1.09; 95％ CI:0.54-2.22; P=0.81)and hospital stay (mean difference,-1.78; 95％ CI:-4.60-1.04; P=0.22) were similar between techniques.Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters.High-quality,large-volume,multi-center RCTs with standard outcome definitions are required.