Predictive model and prognostic insights into duodenal stump fistula following radical gastrectomy with Roux-en-Y reconstruction for gastric cancer

doi:10.4240/wjgs.v17.i6.104333

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

World J Gastrointest Surg. Jun 27, 2025; 17(6): 104333
Published online Jun 27, 2025. doi: 10.4240/wjgs.v17.i6.104333

Table 1 Clinicopathological characteristics, mean ± SD/n (%)

Variables	Categories	nDSF group (n = 318)	DSF group (n = 7)	P value
Age		72.0 (63.2, 78.0)	82.0 (79.5, 85.0)	0.001^a
Gender	Female	102 (32.1)	2 (28.6)	1
	Male	216 (67.9)	5 (71.4)
BMI		22.3 ± 3.7	22.3 ± 3.7	0.620
ASA score	1	71 (22.3)	1 (14.3)	0.757
	2	222 (69.8)	5 (71.4)
	3	25 (7.9)	1 (14.3)
Comorbidity	OVF	18 (5.7)	4 (57.1)	< 0.001^b
	Heart failure or angina	7 (2.2)	0 (0.0)	1
	Bowel obstruction	3 (0.9)	0 (0.0)	1
	Digestive ulcer history	5 (1.6)	0 (0.0)	1
	Abdominal surgery history	44 (13.8)	0 (0.0)	0.617
Tumor marker	CEA	5.7 ± 21.2	5.3 ± 20.1	0.170
	CA-199	44.5 ± 228.9	31.0 ± 85.0	0.737
	AFP	15.4 ± 102.3	9.8 ± 77.3	0.758
Tumor location	Upper stomach	97 (30.5)	1 (14.3)	0.839
	Lower stomach	71 (22.3)	2 (28.6)
	Middle stomach	134 (42.1)	4 (57.1)
	Gastroesophageal junction	13 (4.1)	0 (0.0)
	All or multiple	3 (0.9)	0 (0.0)
Tumor diameter (mm)		63.6 ± 43.0	60.8 ± 41.6	0.291
Pathological type	Adenocarcinoma	197 (61.3)	5 (71.4)	0.993
	Undifferentiated carcinoma	114 (35.8)	2 (28.6)
	Neuroendocrine tumor	4 (1.3)	0 (0.0)
	Lymphoma and others	4 (1.3)	0 (0.0)
	Special types	1 (0.3)	0 (0.0)
pT	pT1-2	134 (42.1)	3 (42.9)	0.602
	pT3-4	184 (57.8)	4 (57.1)
pN	pN0-1	278 (87.4)	5 (71.4)	0.022^a
	pN2-3	40 (12.6)	2 (28.6)
Distant metastasis		43 (13.5)	1 (14.3)	1
pStage	I-II	188 (59.1)	3 (42.9)	0.612
	III-IV	130 (40.9)	4 (47.2)
Non-anastomotic complication (≥ Grade 3a)		52 (16.4)	5 (71.4)	< 0.001^b
Anastomotic complications except DSF (≥ Grade 3a)		11 (3.5)	0 (0.0)	0.993

^aP < 0.05.

^bP < 0.001.

AFP: Alpha-fetoprotein; ASA: American Society of Anesthesiologists; BMI: Body mass index; CA-199: Carbohydrate antigen 199; CEA: Carcinoembryonic antigen; OVF: Obstructive ventilatory failure; pN: Pathological nodal stage; pT: Pathological tumor stage; DSF: Duodenal stump fistula; nDSF: Non-duodenal stump fistula.

Table 2 Perioperative outcomes, mean ± SD/n (%)

Variables	Categories	nDSF group (n = 318)	DSF group (n = 7)	P value
Surgical approach	Laparotomy	129 (40.6)	1 (14.3)	0.210
	Laparoscopy	146 (45.9)	6 (85.7)
	Robot-assisted	43 (13.5)	0 (0.0)
Conversion to open surgery		11 (3.5)	0 (0.0)	1.000
Gastrectomy	DG	129 (40.6)	4 (57.1)	0.621
	TG	189 (59.4)	3 (42.9)
Lymphadenectomy extent	D1, D1 +	146 (45.9)	3 (42.9)	0.800
	D2, D2 +	170 (54.0)	4 (57.1)
Combined resection		48 (15.1)	1 (14.3)	1.000
Surgical time (minute)		324.8 ± 100.6	348.3 ± 62.8	0.369
Blood loss (mL)		72.7 ± 102.9	77.1 ± 90.5	0.659
Retrieved lymph nodes		39.1 ± 17.6	44.9 ± 17.6	0.288
Postoperative hospitalization (days)		17.5 ± 20.2	38.7 ± 11.7	< 0.001^b
Reinforcement of duodenal stump		291 (91.5)	7 (100.0)	0.910
Embedding degree (%)		94.2 ± 13.9	90.7 ± 8.3	0.820
Muscularis and serosa injury		36 (11.32)	2 (28.6)	0.418
Bleeding in reinforcement (mL)		1.5 ± 3.5	1.7 ± 1.9	0.259
Reinforcement duration (minute)		9.1 ± 5.2	9.3 ± 3.2	0.659
Stump suture fixed to the intestinal wall¹		110 (34.6)	0 (0.0)	0.131

^bP < 0.001.

¹In select cases (n = 110), the stump was fully mobilized after embedding and then sutured to the jejunal side wall.

DG: Distal gastrectomy; TG: Total gastrectomy; DSF: Duodenal stump fistula; nDSF: Non-duodenal stump fistula.

Table 3 Univariate logistic regression analysis of the duodenal stump fistula risk factors

Variables (clinicopathological factors)	P value	Variables (perioperative factors)	P value
Age	< 0.001^b	Non-anastomotic complications¹	0.073
BMI	0.945	Anastomotic complications²	1
Gender	0.310	Surgical approach	0.190
ASA score	0.757	Laparoscopic surgery	0.084
OVF	< 0.001^b	Conversion to open surgery	1
Heart failure or angina	1	Gastrectomy	0.622
History of bowel obstruction	1	Lymphadenectomy extent	1
History of digestive ulcer	1	Combined resection	1
History of abdominal surgery	0.777	Surgical time	0.350
CEA	0.494	Blood loss	0.020^a
CA-199	0.033^a	Retrieved lymph nodes	0.423
AFP	0.042^a	Reinforcement of duodenal stump	1
Tumor location	0.735	Embedding degree	0.142
Tumor diameter	0.394	Muscularis and serosa injury	0.395
Pathology type	0.912	Bleeding in reinforcement	0.790
pT	0.276	Reinforcement duration of duodenal stump	1
pN	0.582	Stump suture-fixed to the intestinal wall	0.100
Distant metastasis	1
pStage	0.505

^aP < 0.05.

^bP < 0.001.

¹≥ Grade 3a.

²≥ Grade 3a and except duodenal stump fistula.

Table 4 Multivariate logistic regression analysis of the duodenal stump fistula risk factors

Variables	OR	95%CI	P value
Age	1.201	1.039-1.387	0.013^a
CA-199	0.971	0.916-1.03	0.332
AFP	0.96	0.675-1.365	0.819
OVF	22.431	3.263-154.217	0.002^a
Blood loss	0.998	0.992-1.004	0.523
Stump sutured to the intestinal wall	0.032	0.002-1.028	0.695

^aP < 0.05.