Differences in Early Complications between Circular and Linear Stapled Gastrojejunostomy in Laparoscopic Gastric Bypass

Background

Laparoscopic gastric bypass (LGBP) is the most common bariatric procedure worldwide. The gastrojejunostomy can be stapled with a circular or linear stapler, each with their own specific advantages. We have evaluated differences in postoperative complications between the two techniques.

Methods

We studied operative data and postoperative complications in 560 patients (79.8 % females, median age 42, BMI 42.5) operated with LGBP between 2008 and 2012 at our center. The gastrojejunostomy was initially performed using a circular stapler (CS) in 288 patients and later by linear stapler (LS) in 272. Complications, operative time, and length of stay were retrieved from our database. The risk of developing a port site infection was evaluated with multivariate logistic regression.

Results

Port site infections were more common with CS than LS, 5.2 and 0.4 %, respectively (p?<?0.01). Multivariate analysis demonstrated CS to be an independent risk factor for port site infections (OR 16.3 (2.09–126), p?<?0.01), as well as for stomal ulcers (OR 10.1, 1.15–89, p?=?0.04). Major postoperative complications remained unchanged (anastomotic leak 1.0 vs. 1.1 %, abscess 0.7 vs. 0.4 %), while operative time and length of stay were found to be shorter using the LS (122 vs. 83 min, p?<?0.001 and 4 vs. 3 days, p?<?0.001).

Conclusions

The linear stapled technique yielded lower incidence of port site infections, probably by avoiding the passage of a contaminated circular stapler through the abdominal wall. No difference in major complications was seen, but operative time was shorter using a linear stapler instead of a circular stapler.     

Gastrojejunal Strictures after Roux-en-Y Gastric Bypass With a 21-MM Circular Stapler

Introduction:

Intraluminal staplers for gastrojejunostomy construction during Roux-en-Y gastric bypass (RYGBP) may be associated with postoperative strictures. We analyzed outcomes of a transabdominal circular-stapled RYGBP with evaluation of short- and long-term anastomotic complications.

Methods:

All laparoscopic RYGBPs performed between January 2004 and December 2005 at an academic institution were reviewed. The gastrojejunostomy was created by using the transabdominal passage of a 21-mm intraluminal circular stapler into an antecolic, antegastric Roux limb. This retrospective chart review analyzes patient demographics, anastomotic complications, and weight loss.

Results:

Between January 2004 and December 2005, 159 patients underwent transabdominal circular-stapled RYGBP. Fifteen patients developed a stenosis at the gastrojejunostomy, all requiring endoscopic balloon dilatation. One of these patients required laparoscopic revision of the gastrojejunostomy. Eleven strictures occurred after 30 days, whereas only 4 strictures occurred within 30 days of surgery. Two marginal ulcerations were seen within 1 year of surgery.

Conclusion:

Our 9.4% stricture rate parallels what has been reported in the literature. The majority of strictures were amenable to one endoscopic treatment session. Transabdominal circular-stapled gastrojejunostomy is a reproducible construct for use in bariatric surgery.     

Circular Stapler Size and Risk of Anastomotic Complications in Gastroduodenostomy for Gastric Cancer

Background

A Billroth I reconstruction with a mechanically sutured anastomosis is commonly performed in gastric cancer patients. Some surgeons prefer to use large circular staplers during suturing to minimize risks for anastomotic stricture and gastric stasis after surgery. The effect of stapler size on anastomotic complications has not been validated.

Methods

This study was conducted with 1,031 patients who underwent gastrectomy and Billroth I reconstruction at Samsung Medical Center in Seoul, Korea, between January 2007 and October 2008. Patients were assigned to group A (384 patients) or group B (647 patients) depending on the size of the circular stapler that the surgeon selected for mechanical anastomosis. A 25?mm circular stapler was used for patients in group A, and a 28 or 29?mm circular stapler was used for patients in group B. Postoperative complications were analyzed retrospectively.

Results

The incidence of complications (e.g., gastric stasis, anastomotic stricture, and bleeding) did not differ significantly between groups. Age greater than 60?years was the only significant risk factor for anastomotic complications identified in univariate and multivariate analyses.

Conclusions

Stapler size was unrelated to complications, such as stricture and gastric stasis. Age was the only significant risk factor for anastomotic complications after gastroduodenostomy.     

Low Anastomotic Stricture Rate After Roux-en-Y Gastric Bypass Using a 21-mm Circular Stapling Device

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as a safe and effective procedure for morbid obesity management. Amongst some of the postoperative complications are gastrojejunal (GJ) anastomotic strictures, with an incidence of 3 to 27?% in some series. This study evaluates the incidence of GJ strictures using a 21-mm circular stapling device and its response to treatment with endoscopic balloon dilation.

Methods

A retrospective chart review was conducted of patients who underwent LRYGB between January 2007 and September 2010. We used our previously published technique of retrocolic, retrogastric Roux-en-Y bypass, using a 21-mm circular stapler to construct the gastrojejunostomy. Postoperatively, patients with persistent food intolerance underwent an endoscopy. Those found to have a GJ stricture (defined as inability to pass the endoscope beyond he anastomotic site) underwent pneumatic dilation with a 12-mm balloon.

Results

A total of 338 patients underwent LRYGB. Median follow-up was 57.6?weeks (8?C137). Twenty-two patients underwent an endoscopy due to food intolerance. Sixteen patients (4.7?%, 16/338) were identified with GJ stricture and received at least one endoscopic dilation. The other six patients had a normal endoscopic evaluation. GJ strictures presented at an average of 35?days (13 to 90?days) postoperatively. Four patients underwent two endoscopic interventions, and one underwent three endoscopic interventions.

Conclusions

We hereby demonstrate that the construction of GJ anastomosis with a 21-mm circular stapler is associated with a low stricture rate using our standardized technique. Strictures are amenable to balloon dilatation with subsequent long-term resolution of symptoms.     

Reinforced Circular Stapler in Bariatric Surgery

Background:

Roux-en-Y gastric bypass (RYGBP) is the most common procedure for weight loss surgery but has multiple complications. This study evaluates the use of reinforced circular staplers (RCS) and their effects on reducing gastrojejunal anastomotic complications.

Methods:

We conducted a retrospective chart review from January 2007 to November 2008. Laparoscopic RYGBP were performed in 287 patients. A comparison was made of the complications with and without the use of reinforced circular staplers. The comparison was between a nonreinforced circular stapler (NRCS) group comprising 182 patients and an RCS group comprising 105 patients.

Results:

Complications at gastrojejunal anastomosis were experienced by 15.3% of the patients; 9.5% were in the RCS group and 18.7% were in the NRCS group (P=0.026). Neither group had anastomotic leaks. Bleeding rate was 4.8% in the RCS group vs. 6.6% in the NRCS group. Ulcers occurred in 2.9% of the RCS group vs. 6.0% of the NRCS group. Stricture rate was 1.9% in the RCS group vs. 6.6% in the NRCS group.

Conclusion:

The application of RCS reduced the incidence of gastrojejunal anastomotic complications. Patients are twice as likely to develop complications when no RCS device is used (95% CI 1.03, 4.623). Therefore, it is beneficial to utilize RCS for the gastrojejunal anastomosis in RYGBP procedures.     

A Prospective Randomized Controlled Trial of Semi-mechanical versus Hand-sewn or Circular Stapled Esophagogastrostomy for Prevention of Anastomotic Stricture

Background

Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture.

Methods

Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter.

Results

The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar.

Conclusions

Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.     

Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis

Background

Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.

Methods

Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.

Results

There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.

Conclusions

TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.     

Association Between Circular Stapler Diameter and Stricture Rates Following Gastrointestinal Anastomosis: Systematic Review and Meta-analysis

Background

Stricture is a common complication of gastrointestinal (GI) anastomoses, associated with impaired quality of life, risk of malnutrition, and further interventions. This systematic review and meta-analysis aimed to determine the association between circular stapler diameter and anastomotic stricture rates throughout the GI tract.

Methods

A systematic literature search of EMBASE, MEDLINE and Cochrane Library was performed. The primary outcome was the rate of radiologically or endoscopically confirmed anastomotic stricture. Pooled odds ratios (OR) were calculated using random-effects models to determine the effect of circular stapler diameter on stricture rates in different regions of the GI tract.

Results

Twenty-one studies were identified: seven oesophageal, twelve gastric, and three lower GI. Smaller stapler sizes were strongly associated with higher anastomotic stricture rates throughout the GI tract. The oesophageal anastomosis studies showed; 21 versus 25 mm circular stapler: OR 4.39 ([95% CI 2.12, 9.07]; P?<?0.0001); 25 versus 28/29 mm circular stapler: OR 1.71 ([95% CI 1.15, 2.53]; P?<?0.008). Gastric studies showed; 21 versus 25 mm circular stapler: OR 3.12 ([95% CI 2.23, 4.36]; P?<?0.00001); 25 versus 28/29 mm circular stapler: OR 7.67 ([95% CI 1.86, 31.57]; P?<?0.005). Few lower GI studies were identified, though a similar trend was found: 25 versus 28/29 mm circular stapler: pooled OR 2.61 ([95% CI 0.82, 8.29]; P?=?0.100).

Conclusions

The use of larger circular stapler sizes is strongly associated with reduced risk of anastomotic stricture in the upper GI tract, though data from lower GI joins are limited.

     

Incidence of Gastrojejunostomy Stricture in Laparoscopic Roux-en-Y Gastric Bypass Using an Autologous Fibrin Sealant

Background

Anastomotic leak at the gastrojejunostomy is a life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Fibrin sealants have been used as topical adjuncts to reduce leaks at the gastrojejunostomy. Our clinical observations suggest that an unintended consequence may be the promotion of anastomotic stricture. We hypothesized that the use of fibrin sealant at the gastrojejunostomy in patients undergoing LRYGB decreases the incidence of anastomotic leak but increases the incidence of clinically significant stricture.

Methods

Following institutional review board approval, medical records of patients undergoing LRYGB by two surgeons at a single institution over a 5-year period were retrospectively reviewed. Preoperative demographics and postoperative complication rates including incidence of gastrojejunostomy leak and endoscopically diagnosed stricture requiring dilation within 1 year of surgery were recorded.

Results

Four hundred twenty-five patients had fibrin sealant routinely applied to their gastrojejunostomy site and 104 did not. Four leaks occurred in the sealant group and two leaks occurred in the control group (p?=?0.2). Of patients who received sealant, 1.6 % needed postoperative blood transfusion compared to those 1.6 % of patient who did not receive sealant (p?=?0.05). There was a significantly increased rate of strictures requiring dilation in the sealant group (11.3 % compared to 4.8 % stricture rate in patients who did not receive sealant, p?=?0.04).

Conclusions

In our experience, the use of fibrin sealant at linear stapled gastrojejunostomy site during LRYGB increases the incidence of clinically significant postoperative stricture and does not reduce the incidence of anastomotic leak.     

Embedded Cervical Esophagogastrostomy: A Simple and Convenient Method Using a Circular Stapler After Esophagectomy for Esophageal Carcinomas

Background

Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.

Methods

In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.

Results

A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.

Conclusions

Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.     

Colorectal anastomosis facilitated by the use of the LigaSure® sealing device: comparative study in an animal model

Background

Recently, there has been speculation about the possibility of fusing intestinal tissue using bipolar sealing devices. In this study we compare in a porcine model the anastomoses created using the LigaSure^® device with those created with a stapler after section and closure of a rectal stump.

Methods

Thirty pigs underwent laparoscopic colorectal anastomosis. In group A (n = 15), the division of the intestine and distal stump closure were done with a 10-mm LigaSure Atlas^® device. In group B, these steps were carried out using an endoscopic stapler. Subsequently, the colorectal anastomosis was performed using circular stapling in both groups. The 4-week follow-up included health status, weight gain, blood tests, X-rays, and colonoscopy. Anastomotic tissue was processed to study the mechanical tensile strength and histopathology.

Results

There was no difference in the rate of conversion to open surgery or in average operating time between the groups. In the sealing device group, there was a significantly higher rate of failure in rectal stump closure (p = 0.042). There was one death in group B due to anastomotic leak. There was no difference in adhesion formation or stenosis. Mid-section anastomosis area was 89.7 mm² in group A compared with 100 mm² in group B (p = 0.52). In tensile strength studies, the maximum load resisted by the sample was 13.8 ± 4.9 N (group A) versus 15.7 ± 4.4 N (group B) (p = 0.17). There was no difference between the groups in degree of reepithelialization, number of inflammatory cells, or the presence of microabscesses.

Conclusions

Division and sealing of the rectal stump with the LigaSure^® device is feasible in the proposed experimental model, but it is less reliable than conventional closure with a stapler, since it has a significantly greater failure rate. Therefore, The LigaSure^® device should not be used for this purpose in the clinical setting as this could lead to serious and dramatic complications.     

Greater Weight Loss with the Omega Loop Bypass Compared to the Roux-en-Y Gastric Bypass: a Comparative Study

Background

Despite similar initial results on weight loss and metabolic control, with a better feasibility than the Roux-en-Y gastric bypass (RYGBP), the omega loop bypass (OLB) remains controversial. The aim of this study was to compare the short-term outcomes of the laparoscopic OLB versus the RYGBP in terms of weight loss, metabolic control, and safety.

Methods

Two groups of consecutive patients who underwent laparoscopic gastric bypass surgery were selected: 20 OLB patients and 61 RYGBP patients. Patients were matched for age, gender, and initial body mass index (BMI). Data concerning weight loss, metabolic outcomes, and complications were collected prospectively.

Results

Mean duration of the surgical procedure was shorter in the OLB group (105 vs 152 min in the RYGBP group; p?<?0.001). Mean excess BMI loss percent (EBL%) at 6 months and at 1 year was greater in the OLB group (76.3 vs 60.0 %, p?=?0.001, and 89.0 vs 71.0 %, p?=?0.002, respectively). After adjustment for age, sex, initial BMI, and history of previous bariatric surgery, the OLB procedure was still associated with a significantly greater 1-year EBL%. Diabetes improvement at 6 months was similar between both groups. The early and late complication rates were not statistically different. There were three anastomotic ulcers in the OLB group, in smokers, over 60 years old, who were not taking proton pump inhibitor medication.

Conclusions

In this short-term study, we observed a greater weight loss with OLB and similar efficiency on metabolic control compared to RYGBP. Long-term evaluation is necessary to confirm these outcomes.     

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.     

Intrathoracic Esophagogastric Anastomosis Using a Linear Stapler Following Minimally Invasive Esophagectomy in the Prone Position

Background

Minimally invasive esophagectomy (MIE) in the prone position typically includes thoracoscopic mediastinal dissection and laparoscopic gastric tube construction, followed by esophagogastric anastomosis in the neck. We introduced an intrathoracic esophagogastric anastomosis using linear staplers.

Technique

The lower mediastinal dissection and the gastric tube construction are done in the laparoscopic part of the operation. The esophagus is transected at the cranial level of the aortic arch after the completion of the upper mediastinal lymph node dissection in the prone position. The excess length of the gastric tube is sacrificed before making the anastomosis. Side-to-side esophagogastric anastomosis is performed using a 35-mm endoscopic linear stapler. The entry hole is closed with hand suturing using the posterior and the axillary port.

Results

Twenty-six patients with middle or lower esophageal tumor underwent MIE with an intrathoracic anastomosis. The mean thoracoscopic procedure time was 302 min. One patient had an anastomotic leakage, which was successfully managed with drainage. There has been no anastomotic stenosis. Pneumonia was observed in two patients. There was no mortality.

Conclusions

MIE with an intrathoracic linear-stapled anastomosis with the patient in the prone position is safe and feasible.     

Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model

Background

The accepted palliative treatment for malignant gastric outlet obstruction (GOO) is surgical bypass or placement of self-expandable metal stents. We developed a safe and simple natural orifice transluminal endoscopic surgery (NOTES) technique for gastrojejunostomy using a fully covered, anastomosing metal stent in a porcine model.

Methods

Under general anesthesia, 11 pigs underwent gastrojejunostomy with a 4 cm length anastomosing metal stent. After gastrotomy formation using a needle knife, the jejunum was drawn into the stomach with alligator forceps. A jejunotomy was then performed in the gastric cavity, which was followed by deployment of an anastomosing metal stent under fluoroscopic guidance. Next, the first portion of the duodenum was resected by an endoscopic linear stapler via laparoscopy, thereby creating the model of GOO. Oral feeding was resumed 24 h after the procedure, and animals were euthanized at 1, 2, and 4 weeks after the operation.

Results

Side-to-side gastrojejunostomy was successfully completed through NOTES in 10/11 animals. Ten pigs stayed healthy until the planned sacrifice. The mean gastrojejunostomy procedure time was 41 min (range 15–94 min). By postmortem examination, anastomoses were still intact without intraperitoneal necrosis or adhesion. Histological examination revealed adequate submucosal apposition in all ten experimental pigs undergoing successful endoscopic gastrojejunostomy.

Conclusion

Creating a gastrojejunostomy by NOTES using an anastomosing metal stent seems to be a safe, feasible, durable, and reproducible method for GOO.     

Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy

Background

The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis.

Methods

From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis.

Results

A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis.

Conclusion

Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.     

The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial

Background

Published interim results have shown that fibrin sealant (Tissucol^®/Tisseel^® Baxter AG, Vienna, Austria) may be effective in preventing anastomotic leaks and internal hernias following laparoscopic Roux-en-Y gastric bypass (LRYGBP). We report the final results of a multicenter, randomized clinical trial evaluating the use of fibrin sealant in LRYGBP.

Methods

Between January 2004 and December 2005, 340 patients aged 21–65 years with a body mass index (BMI) of 40–59 kg/m² undergoing LRYGBP were randomized (1:1) to two treatment groups: fibrin sealant group (applied to gastrojejunal and jejunojejunal anastomoses and over mesenteric openings), and control group (no fibrin sealant; suture of the mesenteric openings). Operative time, early and late complications, reinterventions, time to oral diet initiation, and length of stay were assessed.

Results

Overall, 320 patients were included into the study: 160 in the control group and 160 in the fibrin sealant group. All patients completed follow-up assessments at 6 and 12 months, and 60.9% completed assessments at 24 months. There were no significant differences between groups with respect to demographics, operative time, oral diet initiation, hospital stay, and BMI reduction at 6, 12, and 24 months. The incidence of anastomotic leak was numerically, but not significantly, greater in the control group. The overall reintervention rate for specific early complications (<30 days) was significantly higher in the control group (p = 0.016). No deaths or conversions to open laparotomy occurred.

Conclusion

The use of fibrin sealant in laparoscopic RYGBP may be beneficial in reducing the reintervention rate for major perioperative (<30 days) complications. Larger studies are needed.     

Experience with the Circular Stapler for the Gastrojejunostomy in Laparoscopic Gastric Bypass (350 Cases)

Background: The increased incidence of morbid obesity has resulted in an increase in bariatric surgery. The gastrojejunostomy performed during Roux-en-Y gastric bypass (RYGBP) operations has technical variability with different outcomes and complication-rates immediate postoperatively and at long-term follow-up. Methods: Between Jan 2000 and Feb 2005, 350 laparoscopic RYGBP procedures were performed. We present our immediate and follow-up rate of complications with total intraabdominal gastrojejunostomy, performed with the circular stapler. Results: Complications of gastrojejunostomy were detected in 24 patients (6.8%): 3 anastomotic leaks (0.8%); 6 bleeding (1.7%) immediately postoperatively, and 4 stenoses (1.1%), 10 ulcers (2.8%) and 1 stenosis plus ulcer (0.3%) during long-term follow-up. There was no mortality related to the gastrojejunostomy. Conclusions: The gastrojejunostomy with circular stapler is an easily reproducible procedure. The rate of complications has been low. Surgeons who perform laparoscopic RYGBP should have a careful learning curve, and should be aware of the potential complications and their management.     

Symptomatic gallstones after sleeve gastrectomy

Background

Cholelithiasis is a common complication after bariatric surgery. Pure restrictive procedures such as sleeve gastrectomy and gastric banding theoretically should result in less gallstone formation because the food continues to follow the normal gastrointestinal transit, maintaining the enteric–endocrine reflex intact. To the authors’ knowledge, the literature has no studies that analyze the incidence of gallstone formation after sleeve gastrectomy. This study aimed to compare the rates of symptomatic gallstones between laparoscopic Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG).

Methods

A retrospective chart review of patients who underwent laparoscopic RYGBP and SG between 2004 and 2006 was performed. The patients with previous cholecystectomy, known gallstones with or without concomitant cholecystectomy, and previous weight-reduction operations were excluded from the analysis. The outcome measures were the numbers of patients who had experienced symptomatic and complicated gallstones. Using Cox regression analysis, comparisons was made between the patients with laparoscopic RYGBP (group A) and those with laparoscopic SG (group B).

Results

Groups A excluded 174 (26%) of 670 patients, and group B excluded 27 (34.2%) of 79 patients. The patients in group A had a significantly higher preoperative body mass index (BMI) than those in group B. Additionally, more group A than group B patients had a BMI exceeding 45 and more than a 25% loss of original weight. No significant difference in the development of symptomatic (8.7% vs. 3.8%; p = 0.296) or complicated (1.8% vs. 1.9%; p = 0.956) gallstones was noted between the two groups

Conclusions

There was no significant difference in symptomatic or complicated gallstone disease between the patients treated with laparoscopic SG and those treated with laparoscopic RYGBP. Routine prophylactic cholecystectomy should not be recommended for weight reduction during laparoscopic SG.     

Facilitating Intracorporeal Colorectal Anastomoses

Background and Objectives:

An experimental study was undertaken to evaluate whether a previously described technique for laparoscopic sigmoid resection with intracorporeal resection-anastomosis and specimen removal via a suprapubic incision could be facilitated and applied to the rectum.

Methods:

Ten domestic pigs (median weight 41 kg) underwent low anterior resection of the rectum, which was transected with an articulating endoscopic stapler. Pursestring sutures were fashioned intracorporeally with a laparoscopic pursestring clamp. The anvil of a circular stapler was inserted through a 33 mm port into the colon and pursestring tied intracorporeally. A circular gun with a spike fixed to its shaft was introduced per anum and a double-stapled anastomosis performed.

Results:

Complete doughnuts were obtained in all cases and anastomoses were all methylene blue tight. All porcine subjects had an uneventful 5-week postoperative course. The median anastomotic level from the anal verge was 5.2 cm. Histology of colorectal anastomoses revealed healing mucosa.

Conclusions:

The use of articulating endoscopic stapler, laparoscopic pursestring clamp, and circular stapler with a spike fixed to its shaft seems to facilitate a previously described intracorporeal approach to sigmoid resection which was safely applied to the rectum in a porcine model.