Impact of anastomotic orientation (Upward vs. Downward) in Roux-en-Y reconstruction on duodenal stump leakage incidence after radical total gastrectomy: a retrospective comparative study

Abstract

Objective

This study aimed to investigate the impact of anastomotic orientation (Upward vs. Downward) in Roux-en-Y reconstruction on duodenal stump leakage(DSL) incidence following radical total gastrectomy for gastric cancer. Additionally, this study explored the safety, feasibility, and related risks associated with standard upward-oriented Roux-en-Y anastomosis in radical total gastrectomy.

Methods

This retrospective study involved 144 patients who underwent laparoscopic or open radical total gastrectomy by the same surgical team at a single centre. Patients were categorized into two distinct groups according to the type of Roux-en-Y anastomosis: the upward-oriented anastomosis group (n = 60) and the downward-oriented anastomosis group (n = 84). In the upward-oriented group, after completing the dissection of the gastric tumour and regional lymphadenectomy, the specimen was retrieved, and a gastrojejunostomy was performed. The proximal and distal ends of the small intestine were subsequently anastomosed via either a side-to-side or an end-to-side technique.

Results

No statistically significant differences were observed in the general clinical data between the groups that underwent upward-oriented and downward-oriented Roux-en-Y anastomosis (all P > 0.05), making the groups comparable. The incidence of DSL was greater in the downward-oriented anastomosis group than in the upward-oriented anastomosis group; however, this difference was not statistically significant [2.4% (2/84) vs. 0, p = 0.23]. The reoperation rate due to DSL was also higher in the downward-oriented group [1 (1.2%) vs. 0, p = 0.40], and one patient in the downward-oriented group died due to DSL [1 (1.2%) vs. 0, p = 0.40]. The duration of postoperative abdominal drainage was shorter in the upward-oriented group than in the downward-oriented group [90% (54/60) within less than 6 days vs. 57.1% (48/84), p < 0.001]. No statistically significant differences were observed between the two groups with respect to operation time, intraoperative blood loss, number of lymph nodes dissected, TNM stage, length of postoperative hospital stay, or postoperative complications unrelated to DSL.

Conclusion

DSL is a rare yet serious complication. The application of upward-oriented Roux-en-Y anastomosis for digestive tract reconstruction after total gastrectomy for gastric cancer demonstrates comparable efficacy in the recovery of postoperative digestive function to downward-oriented anastomosis methods. Additionally, the upward-oriented approach does not increase the incidence of postoperative DSL or the reoperation rate, nor does it increase the incidence of other catheter-related complications, offering a safe and viable alternative approach. This study provides clinical evidence to support the standardization of Roux-en-Y reconstruction techniques. In addition, conducting early postoperative abdominal CT examinations and providing timely symptomatic treatment can help reduce the severity of duodenal stump leakage and decrease the likelihood of reoperation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-025-14685-w.

Introduction

The International Agency for Research on Cancer (IARC) in the GLOBOCAN 2022 report finds that gastric cancer ranks as the fifth most prevalent malignancy and the fifth leading cause of cancer-related mortality worldwide [1]. Despite significant advancements in the diagnosis and treatment of gastric cancer, surgical resection remains the only curative treatment option for resectable disease [2, 3]. The surgical approaches for gastric cancer have evolved from open surgeries to laparoscopic resections, resulting in significant improvements in outcomes. The scope of indications for laparoscopic surgery has significantly broadened, encompassing not only early gastric cancer but also more advanced stages. Two prospective trials focused on early gastric cancer, KLASS 01 and JCOG 0703, have firmly established the effectiveness and safety of laparoscopic surgery [4, 5].

Roux-en-Y anastomosis is a low-tension anastomosis, and it is considered a safer and more suitable technique for gastrointestinal reconstruction after total gastrectomy than Billroth I and Billroth II anastomosis, as it helps prevent bile reflux and residual gastritis [6, 7]. However, there is a risk of duodenal stump leakage (DSL) following digestive tract reconstruction with Roux-en-Y after radical total gastrectomy for gastric cancer. DSL is a relatively rare but extremely severe complication of Roux-en-Y reconstruction. The reported incidence of DSL ranges from 1 to 5% [8, 9], with a prevalence of 75% and a mortality rate as high as 40% [10, 11]. Research has pinpointed several risk factors for DSL, such as a BMI of 24 kg/m² or above, high preoperative CRP levels, and failure to reinforce the duodenal stump. Additionally, some studies suggest that laparoscopic surgery increases the incidence of DSL, whereas reinforcing the duodenal stump can reduce its occurrence [12]. Conversely, Paik et al. [13] and Ali et al. [14] reported that laparoscopic gastrectomy is not associated with DSL.

In conventional Roux-en-Y anastomosis, the bile and pancreatic limbs tend to droop under gravitational force when the patient is upright, as shown in Fig. 2a, which can lead to compression at the anastomotic junction between the bile-pancreatic limb and the jejunal limb. This mechanical obstruction can significantly increase intraluminal pressure within the duodenum, thereby substantially increasing the risk of DSL. Clinically, DSL is frequently attributed to this mechanism.According to published literature [15], standardized upward-oriented Roux-en-Y reconstruction has been adopted in high-volume Japanese medical centers for gastrointestinal reconstruction. The specific surgical procedure involves the following steps:, After the gastric tumour is isolated and regional lymphadenectomy is performed, the specimen is removed, and gastrojejunostomy is completed. The bile-pancreatic limb is subsequently anastomosed laterally to the jejunal limb with its opening oriented upwards, as depicted in Fig. 2b. This anastomotic configuration ensures that the outflow tract of the bile-pancreatic limb remains patent even when the patient is upright, reducing excessive retention of digestive juices and maintaining lower proximal intestinal pressure, which may mitigate DSL risk.

Fig. 2.

a Downward-oriented Roux-en-Y anastomosis. b Upward-oriented Roux-en-Y anastomosis

To date, no comparative studies have evaluated the differential effects of standard upward-oriented versus downward-oriented Roux-en-Y anastomotic configurations on the incidence of duodenal stump leakage following gastric cancer surgery. This study aims to investigate the impact of anastomotic orientation (standard upward-oriented vs. downward-oriented R-Y reconstruction) on duodenal stump fistula incidence after radical total gastrectomy for gastric cancer.

Materials and methods

General information

This investigation employed a single-centre, retrospective cohort study design.

1. The inclusion criteria were as follows: (1) aged 18 ~ 85 years; (2) histopathologically confirmed diagnosis of primary gastric cancer; and (3) history of radical total gastrectomy with gastrointestinal reconstruction via Roux-en-Y anastomosis.

2. The exclusion criteria were as follows: (1) nongastric cancer patients; (2) individuals not undergoing radical total gastrectomy or Roux-en-Y reconstruction; (3) patients not undergoing radical total gastrectomy or Roux-en-Y reconstruction; and (4) patients with a history of prior gastrointestinal surgery.

3. Group Assignment: Based on detailed review of postoperative surgical records, patients were divided into two groups: (Upward-oriented Group) and (Downward-oriented Group). Group assignment was based solely on the actual anastomotic orientation explicitly recorded in the surgical files.

4. Standardization of Surgical Teams: All procedures were performed by the same senior gastrointestinal surgery team at our institution. The primary surgeons each had over 10 years of experience in gastric cancer surgery and had completed ≥ 500 cases of Roux-en-Y reconstruction, ensuring technical consistency and proficiency.

In accordance with these criteria, we selected patients from the Department of Gastrointestinal Surgery at Xijing Hospital who underwent radical total gastrectomy for gastric cancer between January 2023 and June 2024. A total of 156 cases were initially identified, with 144 ultimately qualifying for inclusion. The age range of the participants was 26 to 78 years (61.6 ± 9.1 years). Among them, 123 were male and 22 were female, all of whom were confirmed preoperatively to have gastric cancer via endoscopic biopsy. The enrolment process is illustrated in Fig. 1. The study group comprised individuals aged 26 to 78 years (60.1 ± 10.1 years), including 49 males and 11 females. The control group included patients aged 41 to 79 years (62.7 ± 8.2 years), consisting of 74 males and 10 females. There was no statistically significant difference in the clinical baseline data between the two groups, as detailed in Table 1. This study received ethical approval from the local institutional ethics committee, and all patient information within the study was anonymized.

Fig. 1.

Study chart

Table 1.

Comparative analysis of the general patient characteristics between the two groups

Factor	Upward-oriented Roux-en-Y	Downward-oriented Roux-en-Y	Volume	P
Number of cases, n	60	84
Gender
Male, n(%)	49(81.7%)	74(88.1%)	χ2 = 1.161	0.281
Female, n(%)	11(18.3%)	10(11.9%)
Age, years	61(26–78)	65(41–79)	t = 1.702	0.091
BMI, kg/m2	22.4 ± 2.9	22.9 ± 3.1	t = 0.868	0.387
History of preoperative chemotherapy	16(26.7%)	25(29.8%)	χ2 = 0.165	0.685
Chronic disease
Diabetes, n(%)	5(8.3%)	11(13.1%)	χ2 = 0.804	0.37
Hypertension, n(%)	6(10%)	16(19%)	χ2 = 2.213	0.137
Types of esophagojejunostomy
Overlap anastomosis	43(71.7%)	61(72.6%)	χ2 = 0.016	0.9
End-to-side anastomosis	17(28.3%)	23(27.4%)
History of abdominal surgery, n(%)	7(11.7%)	12(14.3%)	χ2 = 0.210	0.647
Tumor diameter, cm, median (range)	4(0.8–14)	4(0.5–115)	t = 0.663	0.509
Tumor stage, n(%)
0	1(1.7%)	0	χ2 = 4.326	0.364
I	15(25%)	21(25%)
II	19(31.7%)	28(33.3%)
III	23(38.3%)	35(41.7%)
IV	2(3.3%)	0

Group comparisons conducted through the independent samples t test. Frequency variables were analyzed using the chi-square or Fisher’s exact test

BMI body mass index

Methods

All patients received treatment in accordance with the guidelines outlined by the Chinese Society of Clinical Oncology (CSCO) for the management of gastric cancer [16]. This involved either laparoscopic or open radical total gastrectomy followed by oesophagojejunostomy and subsequent gastrointestinal reconstruction via the Roux-en-Y technique. The surgical procedures adhered to the “Choice of digestive tract reconstruction in upper gastric cancer” [17].

The operating procedure was as follows: patients were placed under general anaesthesia, and either conventional open surgery or laparoscopic techniques were employed. After complete mobilization of the stomach, D2 lymphadenectomy was performed [18]. For oesophagojejunostomy, either the laparoscopic overlap technique or end-to-side anastomosis was utilized. Different techniques were employed for anastomosis of the biliopancreatic limb and jejunal limb following transection of the jejunum. In the study group, a upward-oriented Roux-en-Y anastomosis was implemented, in which the bile-pancreatic limb was anastomosed laterally to the jejunal limb with the opening oriented upwards, as illustrated in Fig. 2b. Conversely, the control group underwent downward-oriented Roux-en-Y reconstruction, with the bile-pancreatic limb anastomosed laterally to the jejunal limb and the opening facing downwards. All patients used linear stapler (EthiconEchelon60) to close the duodenal stump and reinforced with 3–0 Prolene linear serosome suture.

Standardized postoperative management protocol

All patients received standardized postoperative care adhering to Enhanced Recovery After Surgery (ERAS) protocols [19]:

• i.Analgesia: Multimodal pain management was implemented, combining intravenous patient-controlled analgesia (PCA) with nonsteroidal anti-inflammatory drugs (NSAIDs), adjusted according to Visual Analog Scale (VAS) scores.
• ii.Nutritional Support: Enteral nutrition via nasogastric tubes was initiated within 24 h postoperatively, transitioning to oral intake following confirmation of anastomotic integrity by Gastrografin contrast studies on postoperative day 5–7.
• iii.Antimicrobial Prophylaxis: Second-generation cephalosporins were administered for 48 h post-surgery, with escalation guided by culture results if signs of infection (e.g., leukocytosis, fever > 38.5 °C) persisted.
• iv.Complication Surveillance: Daily documentation of abdominal drainage characteristics (volume, color), with measurement of drainage amylase levels on postoperative days 1, 3, and 5. Routine abdominal computed tomography (CT) was performed on postoperative days 3. Anastomotic integrity was confirmed via Gastrografin contrast study between postoperative days 5–7.

Observational metrics and evaluation criteria

Baseline data

A comparative analysis was conducted between the upward-oriented Roux-en-Y anastomosis group and the downward-oriented Roux-en-Y anastomosis group, examining variables such as sex, age, body mass index (BMI), preexisting comorbidities, history of preoperative neoadjuvant therapy, and prior abdominal surgeries.

Surgical details

These details included the method of oesophagojejunostomy, duration of surgery and anaesthesia, and intraoperative blood loss.

Pathological examination

The factors evaluated were the pathological stage of the tumour, the number of lymph nodes dissected, the maximum tumour diameter, and the distance of the tumour from the proximal and distal margins.

Postoperative recovery

This included the time to first postoperative flatus, length of postoperative hospital stay, and duration of postoperative drainage tube placement. Additionally, any postoperative complications, the Clavien‒Dindo classification of these complications, and the approaches adopted for their management were recorded.

Evaluation criteria

• i.Tumour staging was conducted following the 8th edition of the TNM classification system established by the American Joint Committee on Cancer (AJCC) [20].
• ii.The diagnostic criteria for DSL included a postoperative concentration of bilirubin or amylase in the surgical abdominal drainage fluid at least three times greater than normal (excluding pancreatic or anastomotic leakage) or verified leakage alongside abdominal wall drainage, confirmed through imaging techniques such as computed tomography (CT) and/or fistulography [14].
• iii.Postoperative complications: Any complications occurring within one month post-surgery or during the hospital stay were considered surgical complications. The Clavien‒Dindo classification system was employed to evaluate the severity of these complications, with those ranked as Grade 3a or above as adverse events [21].
• iv.Drain Removal Criteria: Persistent drainage output < 50 mL/day for two consecutive days, with amylase concentration in the drainage fluid less than threefold the serum amylase level.

Statistical methods

Analyses used SPSS 26.0 and R 4.5.0. Normally distributed continuous variables reported as mean ± SD (t-tests); non-normal as median[IQR] (Mann–Whitney U tests); categorical as n(%) (χ²/Fisher exact tests). To control confounding, propensity scores were estimated via entropy balancing incorporating diabetes, BMI, and 10 other clinical covariates. Bootstrap resampling (2,000 replicates) with bias-corrected confidence intervals quantified risk differences for anastomotic leakage, with Haldane correction addressing zero events.

Results

Comparison of clinical baseline data and pathological characteristics between the two groups (Table 1)

The demographic and clinicopathological characteristics did not significantly differ between the patients that underwent upward-oriented R-Y anastomosis and those that underwent downward-oriented R-Y anastomosis. The baseline characteristics of the two groups were equivalent, demonstrating their comparability.

Comparison of surgical conditions and postoperative pathological outcomes between the two groups (Table 2)

Table 2.

Comparative analysis of perioperative metrics between the two groups

Perioperative-related indicators		Upward-oriented Roux-en-Y n = 60	Downward-oriented Roux-en-Y n = 84	Volume	P
Operative data
Time of surgery, min, ± SD		249.5 ± 48.0	256.0 ± 47.4	t = 0.806	0.422
Time of anesthesia		312.3 ± 55.3	304.3 ± 55.6	t = −0.849	0.397
Blood loss,ml,median (range)		50(20–500)	50(10–700)	t = 0.464	0.643
Pathologic data
T category	Tis	1	0	t = 1.761	0.78
	T1	13	16
	T2	5	8
	T3	21	33
	T4	20	27
N category	N0	27	34	t = 2.195	0.533
	N1	8	18
	N2	13	20
	N3	12	12
Postoperative recovery
First flatus, d, median(range)		4(3–6)	3(3–5)	z = −1.017	0.309
Postoperative hospital stay, days, (± SD)		9(6–35)	8(5–141)	t = 0.248	0.804
Duration of drainage tube placement ≥ 6		Yes 54(90%)	Yes 48(57.1%)	χ2 = 18.29	0.001*
		No 6(10%)	No 36(42.9%)
Related complications
Intra-abdominal infection		1(1.7%)	3(3.6%)	χ2 = 0.47	0.493
Intra-abdominal hemorrhage		1(1.7%)	1(1.2%)	χ2 = 0.058	0.81
Infarction of the spleen		1(1.7%)	2(2.4%)	χ2 = 0.088	0.76
Pulmonary consolidation and infection		6(10%)	4(4.8%)	χ2 = 1.486	0.22
Massive pleural effusion		0	2(2.4%)	χ2 = 0.058	0.81
Ascites		1	1	χ2 = 0.058	0.81
Pancreatic leakagea		1	0	χ2 = 1.41	0.235
Esophagojejunal anastomotic leak		1(1.7%)	4(4.8%)	χ2 = 1.00	0.317
Duodenal stump leakage		0	2(2.4%)	χ2 = 1.449	0.23
Infectious shock following a duodenal stump leak		0	2	χ2 = 1.449	0.23
Reoperation for duodenal stump leakage		0	1	χ2 = 0.719	0.4
Reoperation for duodenal stump leakage-related death		0	1	χ2 = 0.719	0.4
Clavien–Dindo morbidity
I-II,n,(%)		5(8.3%)	8(9.5%)	χ2 = 0.06	0.81
III-IV,n,(%)		4(6.7%)	4(4.8%)	χ2 = 0.762	0.38

^*Denotes statistical signifcance with p < 0.05

^aPancreatic leakage: Leak criteria ≥ 3 days, amylase 3 × normal [20]

Both groups successfully underwent laparoscopic or open radical total gastrectomy with oesophagojejunostomy, incorporating D2 lymphadenectomy and R-Y anastomotic reconstruction, achieving R0 resection with no adjunctive organ removal or conversion to alternative oesophagojejunostomy methods. Notably, the duration of postoperative drainage tube placement was significantly shorter in the upward-oriented group than in the downward-oriented group (P < 0.05). Nonetheless, no statistically significant differences were observed between the groups with respect to the duration of surgery or anaesthesia, blood loss, tumour margins, length of hospital stay or TNM stage (all P > 0.05).

Comparison of postoperative complications between the two groups (Table 2)

The overall incidence of postoperative complications was 16.7% (10/60) in the upward-oriented group and 14.1% (11/84) in the downward-oriented group, without a statistically significant difference (P > 0.05). The downward-oriented group had a duodenal stump leakage incidence of 2.4% (2/84), whereas no such leaks were observed in the upward-oriented group; however, this difference was not statistically significant (p = 0.23). In the downward-oriented group, two patients developed infectious shock due to duodenal stump leakage. One patient recovered and was discharged following intensive care and multidisciplinary consultation, whereas the other underwent a second surgery but ultimately succumbed to infectious shock and multiorgan failure [1 (1.2%) vs. 0, p = 0.40]. However, the difference in mortality rates associated with DSL between the two groups was not statistically significant.

The most common postoperative complication in both groups was pulmonary infection, which occurred in 10% of the upward-oriented group and 4.8% of the downward-oriented group. In the upward-oriented group, four patients experienced complications classified as Clavien‒Dindo grades III to IV: one case each of pancreatic fistula, oesophagojejunostomy leak, chyle leak, and intra-abdominal haemorrhage. Similarly, in the downward-oriented group, four patients experienced severe complications: two cases of duodenal stump leakage, one oesophagojejunostomy leakage, and one case of massive pleural effusion. With the exception of the patient who died from duodenal stump leakage and multiorgan failure, all patients experiencing complications ultimately improved and were discharged following intensive care and multidisciplinary management. Patients with complications of Clavien‒Dindo grade III or lower received symptomatic treatment postdiagnosis and were discharged upon improvement.

Details of patients with DSL (Table 3)

Table 3.

Details of patients with DSL

No	Age	Sex	BMI(kg/m2)	Surgery	Reinforcement	Diagnostic time(DSL)	TNM (8th)	Complicationsa	Treatment	PHD	Survival
1	48	男	24.2	TG	Presence	POD 2	IIIB	NO	Conservative treatment	29	Survival
2	71	男	24.2	TG	Presence	POD 3	IA	Intraabdominal abscess, pulmonary infection,septic shock,disseminated intravascular coagulation (DIC) and acute renal failure	Reoperation	20	death

BMI body mass index, TG total gastrectomy, POD postoperative day, PHD postoperative hospitalization days, DSL duodenal stump leakage

^aComplications other than DSL (C-D grade 3–5)

Among patients who developed DSL, both were male with ASA grade 2. The mean body mass index (BMI) was 24.2 kg/m². All had undergone laparoscopy-assisted radical total gastrectomy with reinforced duodenal stump closure. DSL was diagnosed on postoperative day (POD) 2 and POD 3, respectively. One patient received conservative management and recovered with aggressive medical therapy before discharge. The other patient, diagnosed with DSL on POD 3, developed septic shock and underwent emergency exploratory laparotomy with duodenal decompression, peritoneal lavage and drainage, and feeding jejunostomy. On POD 13, recurrent fever emerged, accompanied by bright red blood output from abdominal and retroperitoneal drains. This was attributed to intra-abdominal hemorrhage complicated by disseminated intravascular coagulation (DIC) and acute renal failure, with concurrent massive pleural effusions. Despite invasive mechanical ventilation, targeted antibiotics, renal support, and bilateral thoracocentesis with catheter drainage, the patient unfortunately succumbed to multiorgan failure on POD 20.

Adjusted analysis of anastomotic leakage risk (Table 4)

Table 4.

Adjusted analysis of anastomotic leakage risk

Analysis	Risk Difference (RD)	Confidence Intervals		P-value	Interpretation
		95% CI (Percentile)	95% CI (BCa)
Primary Analysis	−0.0231	[−0.0602, 0]	[−0.088, 0]	0.052	Modified group does not increase risk
Sensitivity Analysis (Haldane)	−0.0063	-	[−0.0486, 0.0478]	0.843	No significant difference

Analysis based on 2000 bootstrap replications

BCa Bias-corrected and accelerated

Primary analysis using propensity score-weighted bootstrap resampling (R software; 2,000 replicates) demonstrated a risk difference of −2.31% (95% BCa CI: −8.80%, 0%) for the upward-oriented R-Y group relative to downward-oriented group. Complete analytical code and detailed outputs are provided in Supplementary Materials. The upper confidence limit of 0% indicates no increased risk with the modified approach, though the interval includes the null value (p > 0.05).

Sensitivity analysis incorporating Haldane correction for zero events yielded a risk difference of −0.63% (95% BCa CI: −4.86%, 4.78%). This symmetric confidence interval crossing zero further supports the absence of statistically significant differences between groups.

Discussion

Approximately 9.8% to 31.1% of patients who undergo surgery for gastric cancer developed complications [22, 23]. Of particular concern are surgery-related local complications, which prolong hospitalization, increase treatment costs, and detrimentally affect patient quality of life and overall survival [24]. Among these, DSL represents one of the most severe complications. Despite its relatively low incidence, DSL is linked to elevated rates of unsuccessful conservative treatment and increased mortality [25]. Currently, there is no standardized clinical protocol for managing such cases. To mitigate the incidence and subsequent need for reoperation due to DSL, clinical practice often involves reinforcing the duodenal stump with additional sutures or employing linear staplers reinforced with bioabsorbable polyglycolic acid sheets. These strategies aim to reduce the occurrence of DSL by controlling its risk factors.

R-Y reconstruction is the classic method for digestive tract reconstruction following radical total gastrectomy. However, variations in technique inevitably exist among surgeons due to individual operative preferences and the constraints of laparoscopic visualization and working space. A notable variation is the orientation (upward or downward) of the biliopancreatic limb-to-jejunum anastomosis following duodenal transection. Japanese researchers [26] have reported a higher incidence of cholelithiasis after laparoscopic distal gastrectomy with R-Y reconstruction compared to Billroth-I reconstruction in gastric cancer patients. They proposed that differences in intraluminal duodenal pressure attributable to the reconstruction method contribute to post-operative gallstone formation. This finding underscores the importance of mitigating duodenal pressure after R-Y reconstruction as a key measure for reducing post-operative complications. Consequently, upward-oriented R-Y anastomosis has been adopted as the standard procedure for laparoscopic digestive tract reconstruction after gastric cancer surgery in several high-volume Japanese medical centers. Furthermore, our study demonstrates that upward-oriented anastomosis reduces stasis of digestive fluids within the duodenal stump, thereby lowering intraluminal pressure and potentially decreasing the incidence of duodenal stump leak.

As previously mentioned, although DSL can arise from various causes, the ultimate outcome is primarily due to mechanical obstruction in the biliopancreatic limb following R-Y anastomosis. This obstruction leads to the retention of digestive fluid in the duodenal stump and an increase in duodenal stump pressure, culminating in the manifestation of DSL. In our study, postoperative CT scans of patients who underwent the downward-oriented R-Y procedure for gastric cancer frequently revealed duodenal dilation with luminal fluid accumulation (Figs. 3 and 4). Notably, the staple line of the patient’s duodenal stump was indeed intact, corroborating findings from other studies [9]. Despite the additional suturing reinforcement applied to the duodenal stump for all participants, many patients developed DSL. These observations suggest that impaired outflow of digestive fluid, resulting in increased intraluminal pressure, is the principal cause of DSL.

Fig. 3.

Postoperative dilation of the duodenal stump (biliary-pancreatic limb)

Fig. 4.

Postoperative dilation of the duodenal stump (biliary-pancreatic limb)

By refining the R-Y digestive tract reconstruction technique, we adjusted the direction of the bile-pancreatic limb and jejunal limb anastomosis to prevent mechanical obstruction at the duodenal stump. This modification effectively reduces the incidence of DSL to some extent. In the group that underwent the upward-oriented R-Y procedure, postoperative imaging revealed no cases of duodenal stump dilation, supporting the efficacy of this approach in mitigating the risk of DSL.

The innovative approach of reconstructing the digestive tract via the upward-oriented R-Y method represents a significant advancement. Earlier research identified a variety of risk factors linked to the emergence of DSL, such as preoperative pyloric obstruction resulting in duodenitis [13], elevated C-reactive protein (CRP) levels, obesity, insufficient reinforcement of the duodenal stump [8], afferent loop obstruction [13], and D2 lymphadenectomy [11]. Presently, reinforcement suturing of the duodenal stump is a recognized preventive strategy against DSL, with its effectiveness supported by extensive research. However, despite the implementation of these preventive strategies, DSL still occurs in some patients postoperatively.

This situation prompts a reconsideration of the fundamental causes of DSL and raises the question of whether it can be fundamentally prevented. The inception of the upward-oriented R-Y technique at our centre was driven by this reflection. By altering the orientation of the anastomosis during reconstruction, we aim to facilitate the unimpeded outflow of fluid from the duodenal stump, thereby minimizing the risk of DSL and other serious postoperative complications.

Currently, the primary therapeutic approaches for DSL include surgical and conservative treatments. Although research indicates that nonsurgical treatment is preferred, approximately one-third of patients require emergency surgical intervention because intra-abdominal infections can lead to sepsis. The choice of surgical technique largely depends on the accompanying complications, with peritoneal lavage and drainage forming the foundation of surgical management [12]. Nonsurgical treatments primarily involve pharmacotherapy and percutaneous drainage, which include enteral and parenteral nutritional support, somatostatin administration, drainage of abdominal abscesses, transhepatic biliary drainage, and sealing of fistulas through glue injection [27]. Endoscopic procedures, such as closing the DSL with clips and adhesives or inserting a retrograde decompression tube at the duodenal stump, are also employed [28].

In our study cohort, two patients in the downward-oriented surgery group developed DSL (Figs. 5 and 6), one of whom required surgical intervention. Notably, no patients in the upward-oriented technique group experienced DSL. Tragically, one patient with a duodenal stump fistula complicated by infectious shock and multiorgan failure succumbed to the condition, highlighting the severity and high mortality associated with duodenal stump leaks. These findings underscore the necessity of upward-oriented R-Y anastomosis. Our research suggests that the upward-oriented R-Y technique may reduce the incidence of postoperative DSL and the need for reoperation.

Fig. 5.

Postoperative dilation of the duodenal stump (biliary-pancreatic limb)– The red arrow indicates the dilated bowel

Fig. 6.

Postoperative dilation of the duodenal stump (biliary-pancreatic limb)– The red arrow indicates the dilated bowel and the staple line

In our analysis of patient data, we encountered another patient who developed abdominal distension and discomfort on the third postoperative day. An abdominal CT scan revealed duodenal stump dilation (Fig. 7). Prompt intervention with ultrasound-guided insertion of a nasojejunal decompression tube led to the extraction of a substantial amount of yellow‒green digestive fluid. The patient’s symptoms gradually subsided, and a subsequent CT scan on the seventh day after surgery revealed an improvement in bowel dilation, ultimately preventing the development of a duodenal stump leak. This case serves as indirect evidence supporting our hypothesis that the fundamental cause of DSL is the mechanical obstruction of bile and pancreatic outflow tracts following anastomosis, resulting in elevated pressure in the duodenal stump, which in turn leads to DSL. The clinical management of this case suggests a novel preventive strategy for DSL: conducting postoperative abdominal CT scans to assess the pressure within the duodenal stump and initiating early gastrointestinal decompression to prevent the onset of severe complications such as DSL. However, routine postoperative CT scans inevitably increase medical costs for patients, and the insertion of gastrointestinal decompression tubes can cause unnecessary collateral damage. Moreover, the prolonged presence of these tubes can adversely affect patients’ quality of life. Thus, the true benefit of postoperative CT scans for patients, as well as the criteria for retaining gastrointestinal decompression tubes, requires further clarification. This necessitates additional research with appropriate clinical case data to substantiate and refine these practices.

Fig. 7.

Postoperative dilation of the duodenal stump (biliary-pancreatic limb)– The red arrow indicates the dilated bowel

In conclusion, DSL is a serious yet infrequent complication. The implementation of upward-oriented R-Y anastomosis in postoperative reconstruction of the digestive tract following gastric cancer surgery not only demonstrated comparable efficacy to downward-oriented anastomotic methods in terms of postoperative digestive function recovery but also showed a promising trend in reducing the incidence of DSL and reoperation rates. Importantly, this upward-oriented technique did not increase the incidence of other catheter-related complications, making it a safe and effective approach worthy of broader adoption. Furthermore, this study is the first to propose that varying the orientation of the biliopancreatic limb-to-jejunum anastomosis in R-Y reconstruction may lead to divergent clinical outcomes. This finding potentially provides a theoretical basis for standardizing the application of R-Y anastomosis in digestive tract reconstruction following radical gastrectomy for gastric cancer. Nonetheless, this research has several limitations. Primarily, the sample size is limited and derived from a single centre, which limits the broader representativeness of the findings. Second, as a retrospective study, it is susceptible to patient information and selection biases, with confounding factors that are challenging to control. We posit that the bootstrap analysis demonstrates upward-oriented Roux-en-Y anastomosis does not increase the risk of anastomotic leakage (upper confidence limit ≤ 0%). Current evidence supports the safety profile of this modified technique; however, the presence of only two DSL events precludes definitive statistical conclusions regarding the impact of anastomotic orientation on DSL risk, its comparative advantages over downward-oriented anastomosis warrant validation through future large-scale randomized controlled trials. Therefore, future research should involve multicentre, large-scale prospective studies to further validate the findings of this study.

Authors’ contributions

Study conception: XH and ZY. Study design and protocol development: ZC, YC, YN, and ZR. Statistical analysis: RQ. Drafting of manuscript: ZR. Clinical data collection: YC and YN. CT images analysis and screening: GY and ZR. Final review of manuscript: all authors.

Funding

This study is supported by the Subproject of the Logistics Research Key Project (grant number BKJWS221J004) and the University-level General Clinical Research Project (grant number 2022LC2206).

Data availability

The data that support the findings of this study are not publicly available due to the sensitive nature of the clinical patient information involved, which includes personal privacy concerns. However, the data are available from the corresponding author upon reasonable request. Detailed patient information is securely stored in the electronic medical record system of Xijing Hospital, and access is strictly controlled to ensure compliance with privacy protection regulations.

Declarations

Ethics approval and consent to participate

The study was approved by the the ethical committee of Xijing Hospital. The research protocol strictly followed the ethical principles set forth in the Declaration of Helsinki for Medical Research. Given that our study involved a retrospective analysis of de-identified data collected between January 2023 and June 2024, the requirement for obtaining individual informed consent was waived by the Research Ethics Committee of Xijing Hospital. This decision was consistent with the committee’s guidelines, which permit the exemption of informed consent for studies utilizing anonymized retrospective data without compromising participant rights or privacy.

Competing interests

The authors declare no competing interests.