The overall incidence of duodenal stump fistula (DSF) or duodenal stump leakage is reportedly between 1.6% to 5% and is one of the most serious complications of Billroth-II or Roux en Y reconstruction after gastrectomy for gastric cancer (1,2). DSF is a rare complication but is associated with a high morbidity and mortality rate. The mortality rate of DSF is reported as 16% to 20% (1). This serious complication affects not only patients and their families, but also the surgeon especially in cases with laparoscopic gastrectomy. Several investigators presented their clinical experience, such as the clinical course and the pertinent management of DSF (3,4). It is possible to predict possibilities of DSF in some patients, such as patient’s age, co-morbidity, nutritional status impairment and technical difficulties during surgery (5,6).
During the past two decades, laparoscopic gastrectomy for stage I gastric cancer has become an attractive alternative to open gastrectomy in Korea, Japan and China (7-12). Although the incidence of wound complication in laparoscopic gastrectomy is significantly lower in open gastrectomy, the incidence of overall complication is similar between the two groups (7,8). However, the incidence of major complication, such as DSF or intra-abdominal bleeding in laparoscopic gastrectomy remains unclear (9).
I have performed additional mechanical reinforcement on staple-line of duodenal stump. Herein, we introduced a new and simple surgical technique for reducing DSF during laparoscopic gastrectomy.
Surgical technique (Figure 1)
For laparoscopic gastrectomy in cases of gastric cancer, five trocars were used while standing at the patient’s right side during the entire procedure. After cutting of duodenal stump of about 1–1.5 cm length using linear stapler, Laparoscopic reinforcement suture (LARS) commenced from upper to lower part on staple-line of duodenal stump. Continuous suture with invagination was performed using a barbed suture (Figure 2). In case of patient with short duodenal stump because of chronic ulcer or ectopic pancreas at duodenal bulb or cancer invasion to pylorus, 3 or 4 interrupted sutures without invagination of duodenal stump was conducted using barbed sutures.
In conclusion, DSF after laparoscopic gastrectomy for gastric cancer did not occur in my experience and LARS can be performed in a relatively short operation time without any technical difficulties. LARS on staple-line of duodenal stump can be helpful to prevent DSF after laparoscopic gastrectomy for gastric cancer.
This work was supported by the Dong-A University Research Fund.
Conflicts of Interest: The author has no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
- Cozzaglio L, Giovenzana M, Biffi R, et al. Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study. Gastric Cancer 2016;19:273-9. [Crossref] [PubMed]
- Paik HJ, Lee SH, Choi CI, et al. Duodenal stump fistula after gastrectomy for gastric cancer: risk factors, prevention, and management. Ann Surg Treat Res 2016;90:157-63. [Crossref] [PubMed]
- Cornejo Mde L, Priego P, Ramos D, et al. Duodenal fistula after gastrectomy: Retrospective study of 13 new cases. Rev Esp Enferm Dig 2016;108:20-6. [PubMed]
- Aurello P, Sirimarco D, Magistri P, et al. Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review. World J Gastroenterol 2015;21:7571-6. [Crossref] [PubMed]
- Orsenigo E, Bissolati M, Socci C, et al. Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience. Gastric Cancer 2014;17:733-44. [Crossref] [PubMed]
- Kim KH, Kim MC, Jung GJ. Risk factors for duodenal stump leakage after gastrectomy for gastric cancer and management technique of stump leakage. Hepatogastroenterology 2014;61:1446-53.
- Kim HH, Han SU, Kim MC, et al. Long-term results of laparoscopic gastrectomy for gastric cancer: a large-scale case-control and case-matched Korean multicenter study. J Clin Oncol 2014;32:627-33. [Crossref] [PubMed]
- Kim HH, Hyung WJ, Cho GS, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report--a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg 2010;251:417-20. [Crossref] [PubMed]
- Kim W, Kim HH, Han SU, et al. Decreased Morbidity of Laparoscopic Distal Gastrectomy Compared With Open Distal Gastrectomy for Stage I Gastric Cancer: Short-term Outcomes From a Multicenter Randomized Controlled Trial (KLASS-01). Ann Surg 2016;263:28-35. [Crossref] [PubMed]
- Etoh T, Inomata M, Shiraishi N, et al. Minimally invasive approaches for gastric cancer-Japanese experiences. J Surg Oncol 2013;107:282-8. [Crossref] [PubMed]
- Lu W, Gao J, Yang J, et al. Long-term clinical outcomes of laparoscopy-assisted distal gastrectomy versus open distal gastrectomy for early gastric cancer: A comprehensive systematic review and meta-analysis of randomized control trials. Medicine (Baltimore) 2016;95:e3986. [Crossref] [PubMed]
- Kim MC, Kim W, Kim HH, et al. Risk factors associated with complication following laparoscopy-assisted gastrectomy for gastric cancer: a large-scale korean multicenter study. Ann Surg Oncol 2008;15:2692-700. [Crossref] [PubMed]
- Kim MC. After cutting of duodenal stump of about 1–1.5 cm length using linear stapler LARS commenced from upper to lower or from lower to upper part on staple-line of duodenal stump. Asvide 2017;4:049. Available online: http://www.asvide.com/articles/1356
Cite this article as: Kim MC. Laparoscopic reinforcement suture of duodenal stump using barbed suture during laparoscopic gastrectomy for gastric cancer: preliminary results in consecutive 62 patients. Ann Laparosc Endosc Surg 2017;2:28.