Duodenal stump reinforcement might reduce both incidence and severity of duodenal stump leakage after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer

Abstract

Background Although duodenal stump leakage (DSL) is a relatively rare complication after gastrectomy with Roux-en-Y (R-Y) reconstruction, it is difficult to treat and can be fatal. We investigated the impact of duodenal stump reinforcement on DSL after laparoscopic gastrectomy with R-Y reconstruction for gastric cancer. Methods This retrospective study of 965 patients with gastric cancer who underwent laparoscopic distal or total gastrectomy (LDG or LTG) with R-Y reconstruction compared surgical outcomes between two groups, the duodenal stump reinforcement group (reinforcement group) (n = 895) and that without duodenal stump reinforcement (non-reinforcement group) (n = 70). Results Mean operative duration was significantly longer in the reinforcement than in the non-reinforcement group (LDG; 291 min versus 258 min, p < 0.001, LTG; 325 min versus 285 min, p < 0.001). DSL occurred less frequently in the reinforcement than in the non-reinforcement group (0.67% vs. 5.71%, p < 0.001). Furthermore, non-reinforcement was an independent risk factor for DSL in multiple logistic regression analysis with adjustment for potential confounding factors. Patients with DSL in the non-reinforcement group all required re-operation, while all but one patient with DSL in the reinforcement group recovered with conservative management. Conclusions Duodenal stump reinforcement in laparoscopic gastrectomy with R-Y reconstruction may reduce the risk of DSL development and minimize its severity.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Propensity-score-matched analysis of a multi-institutional dataset to compare postoperative complications between Billroth I and Roux-en-Y reconstructions after distal gastrectomy

“…Several previous large-scale studies reported that the incidence of Fig. 2 Forest plot evaluating the impact of the reconstruction method on overall postoperative complications after Billroth I vs Roux-en-Y gastric reconstruction anastomotic leakage after distal gastrectomy was 1.3-2.4% [14,[24][25][26], if limited to duodenal stump leakage, the incidence were 0-3.2% [11,12,27,28]. The incidence of gastroduodenal anastomosis leakage and duodenal stump leakage in our study were 4.1% and 3.4%, respectively, and were slightly higher than those in the previous studies.…”

Handover method: Simple, classic and harmonized intracorporeal closure of stapled duodenal stump during laparoscopic gastrectomy

“…In the procedure reported by Inoue, 12 the sutures were only placed across the stapled line of the duodenal stump, and both corners of the stapled line were not reinforced and wrapped. Procedure reported by Motonari in 2019 9 requires an experienced assistant with close coordination between the surgeon and assistant, and sometimes leads to reversion of both inverted corners of the stapled duodenal stump during suture placement with removal of forceps. This maneuver prevents easy placement of the reinforcement sutures owing to the use of forceps at the edges; notably, these serve as disadvantages of this approach.…”

“…A few studies have reported that the inadequate duodenal stump closure was considered as the most common contributor to DSL 5–8 . Therefore, adequate duodenal stump closure plays an important role in reducing the incidence of DSL in patients who undergo LG 9 …”

Single Purse-String Suture for Reinforcement of Duodenal Stump During Laparoscopic Radical Gastrectomy for Gastric Cancer

“…The laparoscopic duodenal stump reinforcement was thought to be relatively difficult for most even experienced surgeons to perform due to the complexity of duodenal anastomosis, the restriction of sewing angles, and the uncontrollably of knotting strength (16–18). Based on this situation, we proposed a novel reinforcement method, single purse-string suture, which is an easy and effective method to reinforce the duodenal stump, and could avoid DSL to the some extent.…”

“…Inoue et al demonstrated the effectiveness of intracorporeal Lembert's sutures in laparoscopic distal gastrectomy receiving Roux-en-Y reconstruction while with no postoperative DSL in 223 patients (13). Ri et al reported that duodenal stump reinforcement in laparoscopic gastrectomy with Roux-en-Y reconstruction may reduce the risk of DSL development (0.67% vs. 5.71%, P <0.001) and minimize its severity (16). In addition to the reinforcement suturing of the staple line, Ojima et al introduced a new method, reinforced stapling technique, to reinforce the reconstruction after laparoscopic gastrectomy, which is a feasible and safe procedure for gastric cancer with regard to short-term surgical outcomes (19).…”