title: Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study.
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.
authors.affiliation: Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy. felugia@libero.it.
authors.forename: Luca
authors.initials: L
authors.lastname: Cozzaglio
authors.affiliation: Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Giovenzana
authors.affiliation: Division of Abdominal-Pelvic and Minimally Invasive Surgery, European Institute of Oncology, Milan, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Biffi
authors.affiliation: Division of General Surgery 1, IRCCS Fondazione Policlinico S. Matteo, University of Pavia, Pavia, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Cobianchi
authors.affiliation: Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
authors.forename: Arianna
authors.initials: A
authors.lastname: Coniglio
authors.affiliation: Division of Surgery and Advanced Oncological Therapies, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Framarini
authors.affiliation: Division of Surgery, C. Poma Hospital, Mantua, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Gerard
authors.affiliation: Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Gianotti
authors.affiliation: Department of Surgical Science, University of Padua, Padua, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Marchet
authors.affiliation: Division of Gastrointestinal Surgery and Liver Transplantation, IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mazzaferro
authors.affiliation: Division of Surgery, G.B. Morgagni-L.Pierantoni Hospital, Forlì, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Morgagni
authors.affiliation: Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Orsenigo
authors.affiliation: Department of Surgical Science, Insubria University, Varese, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Rausei
authors.affiliation: Unit of Hepatobiliopancreatic Surgery, Department of Surgery and Translational Medicine, S. Gerardo Hospital, University of Milan-Bicocca, Monza, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Romano
authors.affiliation: Division of Digestive Surgery, Department of Surgical Sciences, Policlinico A. Gemelli, Catholic University Sacro Cuore, Rome, Italy.
authors.forename: Fausto
authors.initials: F
authors.lastname: Rosa
authors.affiliation: Division of General and Minimally Invasive Surgery, Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Rosati
authors.affiliation: Division of Surgical Oncology, Department of Human Pathology and Oncology, University of Siena, Siena, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Roviello
authors.affiliation: Division of General Surgery, Humanitas Clinical and Research Center, University of Milan, Rozzano, MI, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Sacchi
authors.affiliation: Department of Biostatistics, Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Morenghi
authors.affiliation: Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
authors.forename: Vittorio
authors.initials: V
authors.lastname: Quagliuolo
mesh_terms: D000368:Aged; D004378:Duodenal Diseases / Q000401:mortality / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000009:adverse effects; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007412:Intestinal Fistula / Q000401:mortality / Q000601:surgery*; D007558:Italy; D010535:Laparoscopy / Q000379:methods; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Complications; Duodenal stump fistula; Gastrectomy; Surgery