This study evaluated the safety and efficacy of food loop and duodenal stump fixation in patients undergoing distal gastrectomy with Roux-en-Y reconstruction for gastric cancer. Our findings demonstrate that this technique significantly reduces the incidence of RSS without increasing postoperative complications or affecting long-term prognosis.

The significant decrease in RSS incidence (1.1% vs. 8.4%, P = 0.035) observed in our study is a key finding. RSS, a well-recognized complication following Roux-en-Y reconstruction, is characterized by delayed gastric emptying without mechanical obstruction. Our fixation technique, which involves securing the food loop to the duodenal stump, addresses some of the underlying mechanisms of RSS. By stabilizing the anatomical structures of the digestive tract, the technique likely reduces the risk of Roux limb kinking or twisting, which can contribute to RSS. This aligns with our previous research showing that fixing the Roux limb to the duodenal stump can maintain a fluent direction of gastrointestinal anastomosis and avoid cross-angles after jejunojejunostomy [5].

The theoretical basis for RSS reduction through our fixation technique can be explained from multiple perspectives, including mechanical, anatomical, and physiological factors. From a mechanical standpoint, by fixing the food loop to the duodenal stump at a specific arc, this technique creates and maintains a stable anatomical configuration that prevents the Roux limb from twisting or kinking. This is particularly important because RSS often results from mechanical factors such as sharp angulation or rotation of the Roux limb, which can impair peristalsis and cause functional obstruction. The effectiveness of our fixation technique in preventing jejunal angulation is evidenced by both the significantly lower RSS rates and the postoperative contrast studies. By creating a stable arc rather than a sharp angle, this technique maintains a physiological configuration that facilitates normal intestinal transit while preventing the formation of new angulation points.

Beyond mechanical factors, several physiological mechanisms may contribute to the efficacy of our technique. The fixation ensures a smooth and consistent angle at the gastrojejunal anastomosis, which is crucial for maintaining proper motility patterns. Previous studies have shown that the flow angle beneath the gastrojejunostomy significantly influences gastric emptying [7]. Additionally, by positioning the food loop to the right of the ligament of Treitz and preventing its displacement, our technique minimizes the risk of adhesions and internal herniation. The fixed configuration may help preserve the natural myoelectric activity patterns of the jejunum, which are essential for coordinated peristalsis and proper gastric emptying.

While mechanical factors play a crucial role in RSS prevention, our study also considered various physiological and patient-related factors. The impact of nerve innervation damage during surgery is an important consideration, as our standard procedure involves non-preservation of the vagus nerve. However, our fixation technique showed consistent efficacy across different patient subgroups, suggesting that its benefits persist regardless of potential variations in neural integrity. Furthermore, our comprehensive analysis of patient characteristics and comorbidities through multivariate analysis identified several non-mechanical risk factors for postoperative complications, including age ≥ 60 years, smoking history, diabetes, and preoperative hypoproteinemia. This multifactorial approach to understanding surgical outcomes helps provide a more complete picture of the technique's effectiveness and safety profile.

Multiple approaches have been investigated to reduce the incidence of RSS, including Uncut Roux-en-Y reconstruction [8,9,10,11,12], modifications to the anastomotic shape, such as straight anastomosis, side-to-side, and isoperistaltic anastomosis techniques, as well as antecolic reconstruction [7, 13]. Yoshikawa K further demonstrated that adjusting the insertion angle of linear cutting staplers could effectively reduce RSS occurrence [14]. Additionally, shortening the Roux limb length to less than 40 cm has been shown to decrease RSS risk [15]. Qian et al. introduced a simplified Roux-en-Y reconstruction technique that improves both safety and effectiveness[16]. Although these methods have shown promising potential, their efficacy and safety in large-scale clinical trials require further validation. In contrast, our fixation technique provides a novel, straightforward, and effective solution that complements these existing approaches, offering significant reduction in RSS incidence.

Importantly, our study demonstrated that the fixation technique did not significantly increase operative time, estimated blood loss, or overall complication rates. This supports the safety and feasibility of incorporating this technique into standard surgical practice. The fixation procedure is relatively simple, typically requiring only 2–3 min to complete for surgeons proficient in laparoscopic suturing techniques.

The subgroup analysis revealed that the fixation technique maintained safety profile across diverse patient populations, suggesting broad applicability. Our multivariate logistic regression analysis identified several independent risk factors for postoperative complications, including age ≥ 60 years, smoking history, diabetes, and preoperative hypoalbuminemia. These findings align with existing literature on risk factors for complications following gastrectomy and highlight the importance of preoperative risk assessment and management [17,18,19,20,21,22]. Additionally, laparoscopic surgery was associated with a lower incidence of postoperative complications, likely due to its minimally invasive nature, which reduces trauma, blood loss, and postoperative pain, leading to faster recovery [23,24,25].

Regarding long-term outcomes, we found no significant difference in overall survival between the fixation and non-fixation groups. This crucial finding demonstrates that the fixation technique, while effective in reducing RSS incidence, does not compromise long-term survival outcomes. The similar 3-year and 5-year survival rates between the two groups indicate that the short-term benefits of reduced RSS are achieved without any trade-off in terms of long-term prognosis.

The clinical implications of our findings are significant. Incorporating the food loop and duodenal stump fixation technique into clinical practice has the potential to improve postoperative outcomes for patients undergoing distal gastrectomy with Roux-en-Y reconstruction. The simplicity of the technique, coupled with its demonstrated safety and efficacy, makes it a promising addition to the standard surgical approach for distal gastric cancer. To further validate the safety and efficacy of this technique, future research should focus on multi-center studies, long-term functional outcomes and quality of life assessment, comparison with other RSS prevention techniques, cost-effectiveness analysis, and standardization and training protocols.

This study has several limitations. As a single-center, retrospective analysis, our results may have limited generalizability. Despite using propensity score matching to balance baseline characteristics, there may still be unmeasured confounding factors. The relatively small sample size and limited follow-up duration are also significant limitations. Future research should address these limitations through larger-scale, multi-center clinical trials with extended follow-up periods.

In conclusion, our study demonstrates that the food loop and duodenal stump fixation technique in Roux-en-Y reconstruction following radical distal gastrectomy significantly reduces RSS incidence without increasing postoperative complications or affecting long-term survival. This technique potentially improves patients' postoperative recovery and quality of life, and has the potential to become a standard procedure in Roux-en-Y reconstruction for distal gastric cancer patients.