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Po Chu Patricia Y, Ka Fai Kevin W, Fong Yee L, Kiu Jing F, Kylie S, Siu Kee L. Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study. Am J Surg 2020; 220:976-981. [PMID: 32171473 DOI: 10.1016/j.amjsurg.2020.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident. METHODS A retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003-March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed. RESULTS During the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak. CONCLUSION This is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.
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Affiliation(s)
| | | | - Lam Fong Yee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Fung Kiu Jing
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Szeto Kylie
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
| | - Leung Siu Kee
- Department of Surgery, Tuen Mun Hospital, Hong Kong, China
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Zizzo M, Ugoletti L, Manzini L, Castro Ruiz C, Nita GE, Zanelli M, De Marco L, Besutti G, Scalzone R, Sassatelli R, Annessi V, Manenti A, Pedrazzoli C. Management of duodenal stump fistula after gastrectomy for malignant disease: a systematic review of the literature. BMC Surg 2019; 19:55. [PMID: 31138190 PMCID: PMC6540539 DOI: 10.1186/s12893-019-0520-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023] Open
Abstract
Background Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient’s life. DSF is related to high mortality (16–20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer. Methods We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature. Results The 20 included articles covered an approximately 40 years-study period (1979–2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21–39 days, ranging from 1 to 1035 days. Healing time was 19–63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%. Conclusions DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.
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Affiliation(s)
- Maurizio Zizzo
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy. .,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Lara Ugoletti
- General and Emergency Surgery Unit, Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Lorenzo Manzini
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Carolina Castro Ruiz
- General and Emergency Surgery Unit, Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Gabriela Elisa Nita
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Magda Zanelli
- Department of Oncology and Advanced Technologies, Pathology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Loredana De Marco
- Department of Oncology and Advanced Technologies, Pathology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Giulia Besutti
- Department of Imaging and Laboratory Medicine, Radiology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Rocco Scalzone
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Romano Sassatelli
- Department of Oncology and Advanced Technologies, Gastrointestinal Endoscopy Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Valerio Annessi
- General and Emergency Surgery Unit, Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Antonio Manenti
- Department of General Surgery, Azienda Ospedaliero-Universitaria Policlinico, Del Pozzo Street 71, 41124, Modena, Italy
| | - Claudio Pedrazzoli
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
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Cozzaglio L, Giovenzana M, Biffi R, Cobianchi L, Coniglio A, Framarini M, Gerard L, Gianotti L, Marchet A, Mazzaferro V, Morgagni P, Orsenigo E, Rausei S, Romano F, Rosa F, Rosati R, Roviello F, Sacchi M, Morenghi E, Quagliuolo V. Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study. Gastric Cancer 2016; 19:273-9. [PMID: 25491774 DOI: 10.1007/s10120-014-0445-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 11/17/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome. METHODS We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics. RESULTS The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time. CONCLUSIONS Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.
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Affiliation(s)
- Luca Cozzaglio
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
| | - Marco Giovenzana
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Roberto Biffi
- Division of Abdominal-Pelvic and Minimally Invasive Surgery, European Institute of Oncology, Milan, Italy
| | - Lorenzo Cobianchi
- Division of General Surgery 1, IRCCS Fondazione Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Arianna Coniglio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Framarini
- Division of Surgery and Advanced Oncological Therapies, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | | | - Luca Gianotti
- Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Alberto Marchet
- Department of Surgical Science, University of Padua, Padua, Italy
| | - Vincenzo Mazzaferro
- Division of Gastrointestinal Surgery and Liver Transplantation, IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
| | - Paolo Morgagni
- Division of Surgery, G.B. Morgagni-L.Pierantoni Hospital, Forlì, Italy
| | - Elena Orsenigo
- Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Rausei
- Department of Surgical Science, Insubria University, Varese, Italy
| | - Fabrizio Romano
- Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Fausto Rosa
- Division of Digestive Surgery, Department of Surgical Sciences, Policlinico A. Gemelli, Catholic University Sacro Cuore, Rome, Italy
| | - Riccardo Rosati
- Division of General and Minimally Invasive Surgery, Humanitas Clinical and Research Center, Rozzano, MI, Italy
| | - Francesco Roviello
- Division of Surgical Oncology, Department of Human Pathology and Oncology, University of Siena, Siena, Italy
| | - Matteo Sacchi
- Division of General Surgery, Humanitas Clinical and Research Center, University of Milan, Rozzano, MI, Italy
| | - Emanuela Morenghi
- Department of Biostatistics, Humanitas Clinical and Research Center, Rozzano, MI, Italy
| | - Vittorio Quagliuolo
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
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Aurello P, Sirimarco D, Magistri P, Petrucciani N, Berardi G, Amato S, Gasparrini M, D’Angelo F, Nigri G, Ramacciato G. Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review. World J Gastroenterol 2015; 21:7571-7576. [PMID: 26140005 PMCID: PMC4481454 DOI: 10.3748/wjg.v21.i24.7571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/14/2015] [Accepted: 04/09/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.
METHODS: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients’ characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.
RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.
CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.
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