This study aimed to compare patient outcomes after laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction between a group who underwent a duodenal stump reinforcement procedure and those who did not. Our results show that duodenal stump leakage can be avoided by reinforcement with a hand-sewn purse-string suture.
At the institution of the present study, uncut Roux-en-Y reconstruction after laparoscopic distal gastrectomy was initiated in 2014 and has been frequently performed since 2015. Compared with other reconstruction methods after distal or total gastrectomy, such as Billroth Ⅰ or Billroth Ⅱ, uncut Roux-en-Y a reconstruction can positively prevent bile reflux into the residual stomach and esophagus. However, it is also associated with DSF, which is a critical complication following gastrectomy which varies widely in onset time, output, severity, recurrence risk, and outcomes [10–11]. A number of nonsurgical approaches are preferred in the case of DSF, especially for the percutaneous surgeries (e.g. drainage of abdominal abscess and glue injection to obliterate fistula [13, 14]) or the endoscopic surgeries (e.g. application of clips , endoloops, glue , or to close the DSF). However, at least one reoperation would be necessary in more than 1 out of 3 patients. Numerous published case reports as well as various surgical methods have revealed simple surgical therapeutic strategies. Usually, a reoperation is carried out at an early stage, which is often under an emergency condition due to acute sepsis. However, such surgical procedures have not been standardized since they depend on the concurrent complications, including digestive fistula and intraabdominal bleeding. Nonetheless, peritoneal cleaning together with abdominal drainage has laid the foundation of surgical treatment for DSF .
Nevertheless, prevention is always better than cure. Purse-string suture reinforcement of the duodenal stump in Roux-en-Y anastomosis began in our institution September 2015. Duodenal stump leakage was observed in 2 patients (3.7%, n = 54) in our study, while the rate of duodenal leakage reported in other studies (n > 30 cases) was 0.6–3.2% [18–25]. By contrast, no patient in group R had duodenal stump leakage or fistula (0.0%, n = 179), with no significant difference between the two groups (P = 0.053). Nonetheless, other postoperative complications were discovered, including chylous fistula, intraabdominal hemorrhage, anastomotic bleeding, and gastric atony. Our results suggested that the incidence rate of all the above-mentioned postoperative complications in the NR group were higher than that in R group (16.7% vs 2.2%, p<0.001), indicating that purse-string suture reinforcement of the duodenal stump may also improve other postoperative complications. In addition, our findings demonstrated that the time of first flatus and postoperative length of hospital stay in group R were shorter compared with the NR group based on longer operation time (166.76 ± 22.19 vs 182.89 ± 34.15 min, p<0.001), and such heterogeneity might be ascribed to the higher complication rates in the NR group.
Most published papers have not described whether they have reinforced the duodenal stump. Jiang et al.  reported that the duodenum was divided using an endoscopic linear stapler, and duodenal stump rupture could be prevented by interrupted seromuscular sutures. In their study, 2 patients (8.7%) experienced duodenal stump leakage and the authors indicated that the duodenal stump leakage was caused by the torsion of Y anastomosis. They also pointed out that the risk of such torsion would be reduced by the strict closure of the jejunum mesenterium and Petersen cavity. Moreover, the authors concluded that laparoscopic Roux-en-Y reconstruction should be carried out carefully in the hands of experienced laparoscopic surgeons. In our study, the Petersen and mesojejunal defects were closed.
There are several methods for duodenal stump reinforcement. In our institution, the purse-string suture was employed and was an important factor in the duodenum cutting process. For the present study, the duodenum was typically cut from the left side to the right side, which made it easy to invert the duodenum staple line. By contrast, without plans for reinforcement the duodenum would usually be cut through the trocar of the left-upper abdomen. Another important technique of our procedure involved the application of the same trocar in the left-upper abdomen for endoscopic linear stapler and needle forceps. This technique produced an easy axis for sewing so as to invert the staple line. As indicated by the learning curve(Fig. 2), it took us about 10 min to finish the purse-string at the early stage, because of the technical difficulty associated with the procedure. However, the time decreased to 5 min after we had finished 65 purse-string cases. This indicates that purse-string sutures could be easily applied during laparoscopic uncut Roux-en-Y reconstruction without increasing operation time drastically.
Nonetheless, this study was associated with certain limitations due to its retrospective design. Firstly, the study was not a prospective, randomized controlled trial, and there were some changes during the study period. Typically, the most important change was the surgeons’ increasing experience in laparoscopic surgery, which would affect the outcomes.