Analysis Of Risk Factors Related To Duodenal Stump Fistula After Surgery For Gastric Adenocarcinoma And Short-term Efficacy Analysis Of Duodenal Stump Reinforcement

OBJECTIVE:Through this retrospective analysis,the independent risk factors of duodenal stump fistula after gastric adenocarcinoma surgery were explored,and corresponding preventive measures were proposed to reduce the risk of postoperative DSF.METHODS: A total of 649 cases of patients with adenocarcinoma who underwent radical gastrectomy in the Gastrointestinal Surgery Department of the First Affiliated Hospital of Fujian Medical University from January 1,2014 to December 31,2018were included in this study.According to the inclusion and exclusion conditions,data of 610 cases who met the requirements were included in this study.The variable data collected includes general information(include gender,age,BMI value and NRS2002 nutrition score),concomitant disease data(include pyloric obstruction,Diabetes,heart disease,hypertension,hypoalbuminemia,COPD,cirrhosis and Anemia),operation data(include operation method,surgical range,the reconstruction of the digestive tract,the treatment of duodenal stump and the way of nutrition after surgery)and characteristics of Oncology(tumor classification,tumor site,tumor diameter T stage and tumor TNM stage).Univariate analysis was conducted for each variable in the data to determine the factors related to the occurrence of postoperative DSF.And the independent risk factors for DSF after gastric adenocarcinoma surgery were determined by multivariate analysis of these variables based on binary logistic model.RESULTS: By retrospective analysis of the data of 610 patients included,there were26 patients with postoperative DSF,and the incidence of postoperative DSF was4.3%.The univariate analysis results showed that gender,BMI,hypertension during perioperative period,COPD during perioperative period,operation method,surgical range,the reconstruction of the digestive tract,the treatment of duodenal stump,the way of nutrition after surgery tumor type,tumor classification,tumor site,tumor diameter T stage and tumor TNM stage were not associated with DSF after gastric adenocarcinoma surgery(P>0.05);Age,NRS2002 nutritional score,and complications occurred during the perioperative period(including pyloric obstruction,diabetes mellitus,cirrhosis,heart disease,anemia,hypoalbuminemia)were associated with DSF after gastric adenocarcinoma surgery(P < 0.05).Multivariate analysis showed that complications occurred during the perioperative period(include pyloric obstruction,diabetes mellitus and cirrhosis)and NRS2002 nutritional score 3 were independent risk factors for DSF after gastric adenocarcinoma surgery(P<0.05).CONCLUSION: Complications occurred during the perioperative period(include pyloric obstruction,diabetes mellitus and cirrhosis)and NRS2002 nutritional score 3 were independent risk factors for DSF after gastric adenocarcinoma surgery.Therefore,we recommend that postoperative DSF risk assessment be performed for patients undergoing elective surgery for gastric cancer.For patients with perioperative diabetes mellitus,cirrhosis,pyloric obstruction and NRS2002 nutritional score 3,preventive measures(such as controlling blood glucose 11.1mmol/L,improving liver function,applying acid-making agents and gastric mucosa protectant and preoperative nutritional support,etc.)should be taken to reduce the risk of postoperative DSF.OBJECTIVE:In this prospective controlled study,we evaluated the short-term efficacy of different methods of duodenal stump management(reinforcement or not),and provided a reference for the choice of methods of duodenal stump management during clinical surgery.METHODS: This study is expected to enroll 100 patients for 2 years.Inclusion criteria are as follows: patients with gastric cancer who underwent radical distal gastrectomy or total gastrectomy with B-II anastomosis or Roux-en-Y anastomosis(meeting the diagnostic criteria),who were histologically confirmed to be gastric adenocarcinoma after surgery.The primary endpoint was DSF within 30 days.Secondary endpoints were early postoperative outcomes up to discharge or death.Data were collected including baseline data(gender,age,BMI,comorbidities,surgical and oncology characteristics)and outcome data(DSF,other short-term complications,Clavien-Dindo classification,postoperative hospital stay,length of surgery,and total hospital cost).By comparing the outcome data of the two groups of patients,the short-term efficacy of the above two stump management methods was evaluated.RESULTS: A total of 99 patients completed this study,49 in the experimental group and 50 in the control group.DSF occurred in 3 patients and other short-term complications occurred in 13 patients.Through the comparative analysis of the two groups of data,there were no significant differences between the experimental group and the control group in the incidence of DSF and other short-term complications,the Clavien-Dindo classification,the length of surgery,the number of days of postoperative hospital stay,and the total cost of hospital stay.CONCLUSION: There was no significant difference in short-term efficacy between duodenal stump reinforcement and non-reinforcement.Reinforcement of the duodenal stump does not reduce the risk of postoperative DSF.During surgery,the duodenal stump may not be repaired if it is closed satisfactorily.The trial has been registered with Clinical Trials.gov(NCT01938313).