Staple line failure, or more generally, technical failure of the duodenal stump closure, consti­tutes probably the most basic and obvious cause of stump blowout. Prior to the widespread use of standardized surgical stapling devices, hand­sewn two-layered closure without tension was the technique of choice [10]. With the introduc­tion of surgical staplers, hand-sewn closure of the duodenal stump has lost popularity, but the underlying mechanisms of failure remain un­changed; namely, ischemia and/or incomplete closure. With a hand-sewn closure, the most common technical error is not incomplete clo­sure with resultant leakage, but rather overag­gressive use of suture, which results in ischemia at the line of closure. The ischemic tissue at the site of aggressive suturing can eventually ne­crose, with catastrophic results. Starting in the 1970s and 1980s, surgical staplers began to re­place sutured techniques for closing the duodenal stump. While providing a simple, efficient, and watertight closure, staples were not a panacea for stump blowout. When using a surgical stapler de­vice, improper selection of staple size and failure to appreciate tissue thickness and edema can lead to excessive compression at the staple line simi­lar to sewn closures, with subsequent ischemic breakdown. Furthermore, flawed stapler tech­nique and aggressive dissection and devascular­ization can contribute to inadequate closure and increase the risk of staple line failure.

Managing the intraluminal pressure in the duo­denal stump has gained renewed attention as an important factor in reducing the risk of stump blowout. Distal obstruction, regardless of etiol­ogy, will eventually lead to high enough stump pressures to disrupt even the most secure and technically sound closure. While much work has been done studying intact gastrointestinal tract both anatomically and functionally, scant litera­ture has focused on the behavior of the surgically

hormones, including insulinlike growth factor, TGF-beta, VEGF, fibroblast growth factor, epi­dermal growth factor, and PDGF are essential in the progression of anastomotic healing [12]. Mal­nutrition, by way of inadequate substrate avail­ability and decoupling of this tightly controlled axis of growth hormone regulation, can impede wound healing and contribute to stump break­down and blowout.

Bancroft’s closure, first described in 1932, begins with a submuscular dissection starting in the dis­tal antrum and progressing toward the duodenum [13]. The stomach is then divided, and dissection is carried down around the circumference of the antrum distally. Once the antral mucosa and sub­mucosa have been dissected in their entirety to the duodenal junction, a frozen section confirms the presence of duodenal mucosa and this is then closed. Following mucosal approximation, the excess antral muscle tissue is trimmed and clo­sure is completed with a running nonabsorbable suture line (see Fig. 15.3). While Bancroft’s clo­sure can be a useful strategy in the management of a difficult duodenum during distal gastrecto­my, this approach must be planned for early in the operation. As the technique relies on viable tissue around the distal antrum, the right gastric and gastroepiploic arteries, which are typically ligated at the beginning of the dissection, must instead be preserved.