A duodenal stump fistula (DSF) forming after a gastrectomy for gastric cancer is a life-threatening complication. Even though the overall incidence is low (1.8%–3%), the DSF-related mortality rate is reported to be 7% to 67% [123]. There are many DSF-related complications leading to longer hospitalization times, such as intra-abdominal abscesses, wound infections, diffuse peritonitis, sepsis, malnutrition, pancreatitis, abdominal bleeding, and pneumonia [1].

DSF is thought to be caused by many factors such as inadequate closure of the duodenal stump, devascularization, cancer involvement or resection, an inflamed duodenal wall, local hematoma, incorrect drain position and postoperative distension of the duodenum [4]. Orsenigo et al. [5] first reported the risk factors associated with postoperative DSF to be heart disease, liver cirrhosis, intraoperative blood loss (>300 mL) and the absence of manual reinforcement. However, that analysis focused on intraoperative factors. The aim of the present study was to analyze the risk factors for DSF that could be revealed during the preoperative evaluation for obtaining informed consent before surgery. By identifying them, we should be able to pay more attention to patients who are in high-risk groups during the surgery and postoperative management. The risk factors for DSF after gastrectomy for gastric cancer were analyzed retrospectively, and we also describe the methods used for prevention and management of DSF in our institution.

The records of 1,018 consecutive patients who underwent curative gastrectomy from November 2008 to December 2013 were reviewed retrospectively. All of the patients had gastric cancer. Among them, 716 had a duodenal stump after gastrectomy. The methods used for intestinal reconstruction were Billroth II gastrojejunostomy (B-II) with jejunojejunostomy (Braun's anastomosis) or Roux-en Y (R-Y) gastrojejunostomy for subtotal gastrectomy and R-Y esophagojejunostomy for total gastrectomy.

DSF was diagnosed by the presence of duodenal fluid in the surgical drainage and confirmed by a CT scan when needed. The location of any tumor in the stomach was classified into 4 regions: antrum, stomach angle to lower body, mid body to high body, and cardia/fundus [6].

DSF after gastrectomy for gastric cancer is a rare complication with an incidence of 1.8%–3% [123]. However, once DSF occurs it is a life-threatening complication with a mortality rate of 7%–67% [123]. In our study, the incidence of DSF was 2.2% and the mortality rate was 12.5% in those patients. One patient died from sepsis and bleeding and the other patient died from pneumonia following DSF. These are common complications from DSF [1].

Various factors have been reported to cause DSF [4]. Orsenigo et al. [5] first reported the risk factors associated with postoperative DSF to be heart disease, liver cirrhosis, intraoperative blood loss (>300 mL), and the absence of manual reinforcement. We found here that age, ASA score, pathology T stage, tumor location, GOO, DM, and multiple comorbidities were significant factors for DSF in the univariate analysis. Multivariate analysis showed that GOO (OR, 5.62; 95% CI, 1.45–21.71) and multiple comorbidities (OR, 3.92; 95% CI, 1.30–11.80) were the main risk factors for DSF after gastrectomy for gastric cancer. GOO occurs more frequently when gastric cancer locates in lower body, i.e., antrum. GOO can also cause inflammation at surrounding duodenal wall tissues. For these reasons, we secure more distal margin because of the danger that cancer can involve at resection line, and eventually more devascularization is required. This is why we think GOO could be a risk factor of DSF shown in our study [47].

GOO and multiple comorbidities are both easily revealed during preoperative evaluation for DSF (Fig. 1). Patients can be categorized into high-, and low-risk groups. High-risk patients are those who have GOO or multiple comorbidities. Low-risk patients are those who have no symptoms of obstruction and no more than a single comorbidity. This means that we can anticipate the risk before the operation and prepare to make an appropriate decision when DSF is doubtful. Moreover, the surgeon can pay more attention during the operation to prevent DSF from occurring.

To prevent DSF during surgery, we used an absorbable reinforcement felt (Neoveil, Gunze Limited, Shenzhen, China) [8910] and a fibrin sealant (Tisseel, Baxter AG, Wien, Austria) [1112] on the duodenal stump. First, we applied the fibrin sealant onto the duodenal stump and then sealed it with the absorbable reinforcement felt. The fibrin sealant was then reapplied to prevent DSF (Fig. 2).

Many methods have been proposed for the treatment of DSF such as surgical management, a percutaneous approach, enteral and/or TPN, and therapy with somatostatin and its analogues. The usual surgical treatments are tube duodenostomy [13], repair with a rectus abdominis muscle flap [14], closure by Rouxen-Y duodenojejunostomy [15], and pancreaticoduodenectomy [16]. The usual methods of a percutaneous approach are abscess drainage, transhepatic biliary drainage [1718], fistula closure using cyanoacrylate or prolamine [19], percutaneous transhepatic biliary drainage (PTBD), occlusion balloons [20] or Foley balloon catheter [21].

Three patients in our study underwent a reoperation involving primary repair of the duodenal stump using choledochostomy and feeding jejunostomy. Ultrasound-guided PTBD was performed for six of them (Fig. 3). The other seven patients recovered with supportive care. The mean duration of hospital stay after surgery was 29.4 days.

In conclusion, DSF is a life-threatening problem after gastrectomy for gastric cancer. Comorbidity and GOO were independent risk factors for DSF in our multivariate analysis. We generated a flow chart for risk factors based on these results. Surgeons could use this and pay more attention to prevent DSF in high-risk groups, and manage them more aggressively when DSF is anticipated.