title: Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Aurello
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Dario
authors.initials: D
authors.lastname: Sirimarco
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Magistri
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Niccolò
authors.initials: N
authors.lastname: Petrucciani
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Giammauro
authors.initials: G
authors.lastname: Berardi
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Amato
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Marcello
authors.initials: M
authors.lastname: Gasparrini
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: D'Angelo
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Nigri
authors.affiliation: Paolo Aurello, Dario Sirimarco, Paolo Magistri, Niccolò Petrucciani, Giammauro Berardi, Silvia Amato, Marcello Gasparrini, Francesco D'Angelo, Giuseppe Nigri, Giovanni Ramacciato, Department of General Surgery, Sant'Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ramacciato
mesh_terms: D057868:Anastomotic Leak / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D004322:Drainage; D004378:Duodenal Diseases / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D004386:Duodenum / Q000473:pathology / Q000601:surgery*; D005743:Gastrectomy / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D007902:Length of Stay; D012086:Reoperation; D013274:Stomach Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing
keywords: Duodenal stump fistula; Duodenal stump leak; Gastrectomy; Gastric cancer; Management