Role of routine intraoperative endoscopy in laparoscopic bariatric surgery

Training in bariatric and metabolic endoscopy

The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.

Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality.

RESULTS

Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)].

CONCLUSIONS

IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Endoscopy in the early postoperative setting after primary gastrointestinal anastomosis

INTRODUCTION

Gastrointestinal anastomoses may require early evaluation and treatment via flexible endoscopic techniques when complications arise. There is reticence, however, to perform endoscopy given the applied mechanical forces. We aimed to identify the incidence of gastrointestinal anastomotic perforation or disruption resulting from endoscopy performed ≤6 weeks of anastomoses.

METHODS

Review of patients from 2002 to 2013 who underwent flexible endoscopy within 6 weeks of creation of gastrointestinal anastomosis. Exclusion criteria included intraoperative endoscopy, anastomotic perforation prior to endoscopy, and endoscopy remote from the anastomotic site. Data are presented as median (interquartile range; IQR) or percentages as appropriate.

RESULTS

Twenty-four patients met our criteria (age 69 years [IQR 54-77], 54% men]). Endoscopy was performed at a median postoperative time of 18 days (IQR 8-30). Indications for endoscopy included bleeding (66%), obstruction (13%), pain (13%), concern for pancreatic duct leak (4%), and concern for ischemia (4%). Six patients underwent therapeutic endoscopic procedures including coagulation (8%), balloon dilation (8%), tube decompression (8%), and stent placement (4%). There were no anastomotic perforations or disruptions as a result of endoscopy.

CONCLUSION

Despite theoretical risks of adverse events of flexible endoscopy in the early postoperative period, no endoscopic perforations or disruptions occurred in recently created surgical anastomoses.

Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).

The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery

There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.

Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection--comparative study

The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead-Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1 kg/m(2) (mean follow-up: 15.7 months) and in gastric sleeve group 50.3 and 33.5 kg/m(2) (mean follow-up: 38.3 months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead-Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastric sleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeve resection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection. Ninety-two percent of the gastro-oesophageal reflux were resolved in the bypass group and 25% in the sleeve (with 33% progression) group. Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.

Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond

INTRODUCTION

The aim of this study is to determine the role of intraoperative endoscopy in identifying gastrojejunostomy leak in laparoscopic Roux-en-Y gastric bypass (LRNYGB) and to define other roles that can be achieved by this diagnostic maneuver.

METHODS

A retrospective chart review of all patients who underwent LRNYGB at both Cleveland Clinic (USA) and Adan Hospital (Kuwait) was undertaken. All operations were performed by 2 surgeons (B.C. and F.A.).We analyzed the following parameters in the patients: mean age, estimated blood loss, average hospital stay, the number of patients who had intraoperative leaks, and those who developed intraoperative pouch bleeding.

RESULTS

Between July 2004 and January 2009, 290 patients (244 women-85% and 46 men-15%) were operated upon with a mean age of 42 years (range: 19 to 61 y). The average body mass index was 48 kg/m2 (range: 35 to 65 kg/m2), and the average American Society of Anesthesiology classification of 3 (range: 2 to 4). Mean estimated blood loss of 95 mL (range: 27 to 310 mL) and the mean operative time was 165 minutes (range: 102 to 348 min). The average hospital stay was 3 days (range: 2 to 13 d). Eleven patients (3.7%) developed intraoperative leaks that were controlled intraoperatively. Ten patients (3.4%) developed intraoperative pouch bleeding, in 6 of them the bleeding vessel was controlled laparascopically. No documented postoperative leak in this series of patients. One patient (0.34%) underwent diagnostic laparoscopy for clinical suspicion of a leak which could not be identified.

CONCLUSIONS

Intraoperative endoscopy for LRNYGBP may reduce the leak rate postoperatively and also, may minimize postoperative endoscopy and surgical intervention for gastrointestinal bleeding.

Significance of intraoperative endoscopy in total gastrectomy for gastric cancer

BACKGROUND

Anastomotic impairment can be a major cause of surgical complications in gastrointestinal surgery. The aim of this study was to evaluate the efficacy of intraoperative endoscopy (IOE) in esophagojejunal anastomosis for detection of anastomotic impairment.

METHODS

Forty-eight patients who underwent total gastrectomy were evaluated for the integrity of the esophagojejunostomy using IOE at completion of mechanical esophagojejunal anastomosis.

RESULTS

Overall postoperative anastomotic leakage (PAL) rate was 4.2% (n = 2/48). Both patients who developed PAL had abnormal findings such as mucosal defect in the esophageal mucosa or incomplete anastomotic stapling. Also, IOE revealed inadvertent anastomotic failure in three patients: two jejunal and one esophageal occlusion. There were no complications due to IOE.

CONCLUSION

IOE is safe and may easily provide significant information that can minimize PAL by detecting anastomotic failure on esophagojejunal anastomosis.

Endoscopy in the obese patient

Obese patients present many unique challenges to the endoscopist. Special consideration should be given to these patients, and endoscopists need to be aware of the additional challenges that may be present while performing endoscopic procedures on obese patients. This article reviews the special risks that obese patients face while undergoing endoscopy, endoscopic management of patients postbariatric surgery, and future role of endoscopy in the management of obese patients.

Gastric gastrointestinal stromal tumor (GIST) incidentally found and resected during laparoscopic sleeve gastrectomy

The incidence of incidental pathology found during laparoscopic bariatric surgery has been estimated to be around 2%, and gastric gastrointestinal stromal tumors (GISTs) have been found in 0.8% of patients, constituting a rather uncommon finding. Safe laparoscopic resection of gastric GISTs is an established procedure and has been described associated to gastric Roux-en-Y bypass for morbid obesity. We discuss one case of a gastric GIST incidentally discovered during laparoscopic sleeve gastrectomy for morbid obesity. The procedure was performed via laparoscopy, and the patient recovered without any complication. Currently, the patient has lost weight according to what was expected, is asymptomatic, and free of disease.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Endoscopic management of early upper gastrointestinal hemorrhage following laparoscopic Roux-en-Y gastric bypass

BACKGROUND AND AIMS

Upper gastrointestinal hemorrhage (UGIH) is an infrequent complication (1-3.8%) following laparoscopic Roux-en-Y gastric bypass (LRYGB). The safety and efficacy of endoscopic management of immediate postoperative bleeding is unknown. We sought to determine how frequently UGIH complicates LRYGB and whether endoscopic management is successful in controlling hemorrhage.

METHODS

Retrospective chart review of all patients who developed UGIH following LRYGB from November 2001 to July 2005 at a large suburban teaching hospital.

RESULTS

Of 933 patients who underwent LRYGB, 30 (3.2%) developed postoperative UGIH. An endoscopic esophagogastroduodenoscopy (EGD) was performed in 27/30 patients (90%). All were found to have bleeding emanating from the gastrojejunostomy (GJ) staple line. Endoscopic intervention was performed in 24/30 (80%) with epinephrine injection and heater probe cautery being used most commonly. Endoscopic therapy was ultimately successful in controlling all hemorrhage, with 5 patients (17%) requiring a second EGD for rebleeding. No patient required surgery to control hemorrhage. One patient aspirated during the endoscopic procedure with subsequent anoxic encephalopathy and died 5 days postoperatively. Twenty-one patients (70%) developed UGIH in the intraoperative or immediate postoperative period (<4 h postoperative). The mean length of stay was significantly longer in these patients (2.84 vs 4.1, P= 0.001).

CONCLUSIONS

(a) UGIH complicates LRYGB in a small but significant number of patients. (b) Bleeding usually occurs at the GJ site. (c) EGD is safe and effective in controlling hemorrhage with standard endoscopic techniques. (d) UGIH occurs most commonly in the immediate postoperative period and may be best managed in the operating room with the patient intubated to prevent aspiration.

Techniques of laparoscopic gastric bypass: on-line survey of American Society for Bariatric Surgery practicing surgeons

BACKGROUND

Various techniques have been used for laparoscopic gastric bypass. This study was performed to survey American Society for Bariatric Surgery practicing surgeons on how they perform laparoscopic gastric bypass.

METHODS

An Internet-based survey was sent to all practicing surgeons in the American Society for Bariatric Surgery database by way of e-mail. The survey was divided into sections, including experience, pouch, limbs, gastrojejunostomy (GJ), jejunojejunostomy, and band. The survey results were collected from the Internet site after 4 months.

RESULTS

A total of 215 surgeons responded; 98% stated they performed laparoscopic gastric bypass. The surgeons had performed an average of 423 cases in their career and 95 cases during the past 12 months. The average pouch size was 25 cm(3) and approximately one half of the surgeons (49%) measured the pouch size by the distance for the gastroesophageal junction. Almost all surgeons (99.5%) performed Roux-en-Y and not loop GJ. The average biliopancreatic limb length was 48 cm, and the average Roux limb was 114 cm. About one half of the surgeons (46%) measured the limb length with an open grasper, and few (7%) used a suture or umbilical tape. The antecolic and antegastric approaches were the more common. The percentage of those using the circular stapler, linear stapler, and hand sewing was 43%, 41%, and 21% for the GJ technique. Most surgeons (93%) routinely tested the GJ intraoperatively. The percentage of those using staple anastomosis and hand-sewn common enterotomy, double stapling, triple stapling, and hand sewing was 53%, 36%, 13%, and 1% for the jejunojejunostomy technique. Most surgeons (94%) closed at least one mesenteric defect. Also, most surgeons (95%) did not place a band around the pouch.

CONCLUSION

Technical variations exist in how laparoscopic gastric bypass procedures are performed by American Society for Bariatric Surgery practicing surgeons. Additional research is needed to explore the links between the technical variations and outcomes.

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although this remains controversial. The aim of this study was to analyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolic-routed Roux limb.

METHODS

During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performed by one of three bariatric surgeons. The decision to perform antecolic versus retrocolic LRYGBP was left to the surgeon's preference. The primary outcome measure was anastomotic leak.

RESULTS

Mean follow-up was 28 weeks. There were no perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P=0.04).

CONCLUSION

Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.

Intraoperative endoscopic pneumatic testing for gastrojejunal anastomotic integrity during laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Gastrojejunal anastomotic leaks remain a major source of morbidity following laparoscopic gastric bypass. Intraoperative pneumatic testing has been offered as a method to reduce the incidence of this complication. This study's purpose was to assess the efficacy of intraoperative pneumatic testing during laparoscopic gastric bypass, to evaluate the types of air leaks detected, and to develop an algorithm for management that takes into account air leak categorization and drainage.

METHODS

A retrospective analysis was performed on the initial 257 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 36-month period. The gastrojejunostomy was constructed using a linear stapler technique. All patients underwent intraoperative endoscopic pneumatic testing with a clamp applied to the Roux limb. All patients underwent water-soluble upper gastrointestinal radiography on the first postoperative day.

RESULTS

Patients were divided based on the pneumatic testing results into groups for data analysis: persistent air leak (group 1), non-reproducible air leak (group 2), and no air leak (group 3). The overall age (41.7+/-9.3 years), body mass index (BMI) (47.3+/-6.4 kg/m2), conversion rate (2%), and length of stay (1.9+/-2.0 days) were not statistically different among groups (p>0.05). In group 1, the air leak site was repaired, and 11 (92%) were drained. In group 2, the air leak site could not be identified, and all 12 (4.7%) were treated by drainage alone. In group 3, drains were placed in 12 (5.2%) due to difficult construction of the gastrojejunostomy. Overall postoperative gastrointestinal leak rate was 0.78%. No postoperative clinical or radiological gastrointestinal leaks occurred within the region tested pneumatically. Intraoperative complications related to pneumatic testing occurred in 1 (0.39%) patient.

CONCLUSIONS

Intraoperative pneumatic testing of the gastrojejunal anastomosis is a safe and rapid means of evaluating anastomotic integrity. Application of this technique permitted timely repair of flawed anastomoses, thereby averting potential postoperative leaks.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BACKGROUND

The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.

METHODS

All patients who underwent LRYGB at the authors' institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.

RESULTS

This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).

CONCLUSIONS

According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

Laparoscopic Repair of Gastrointestinal Leaks after Laparoscopic Gastric Bypass

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75–182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4–78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.

Endoscopic evaluation of the gastrojejunostomy in laparoscopic gastric bypass

BACKGROUND

A significant and potentially deadly complication of the Roux-en-Y gastric bypass is leakage from the gastrojejunostomy (GJ). The aim of our study was to evaluate the efficacy of intraoperative endoscopy in preventing postoperative anastomotic leakage.

METHODS

The study enrolled 340 consecutive patients undergoing laparoscopic gastric bypass procedures performed from January 2001 to July 2004. In all cases, an endoscopist performed video gastroscopy to evaluate the integrity of the GJ using air insufflation of the pouch after distal clamping of the Roux limb. Intraoperative leaks were repaired and the anastomosis was retested. Demographic, operative, and endoscopic data were collected and analyzed. Logistic regression was used in both univariate and multivariate modeling to identify independent preoperative variables associated with the presence of intraoperative leak. Model parameters were estimated by the maximum likelihood method. From these estimates, odds ratios (ORs) with 95% confidence intervals (CIs) were computed.

RESULTS

There were no postoperative anastomotic leaks or mortalities in our series. Overall, endoscopic evaluation of the GJ resulted in the detection of 56 intraoperative leaks (16.4%). There was a significant difference in the incidence of intraoperative leakage for patients older than 40 years (21%) vs those younger than 40 years (10.5%; p = 0.01). In the initial 91 cases, the GJ was performed by the end-to-end anastomosis (EEA) technique; the subsequent 249 were performed with a combination of linear stapling and handsewn technique. There was a trend toward more leakage in the GIA group (18%) versus EEA (12%); however, the difference was not significant (p = 0.188). Age remained an independent risk factor for leak detected intraoperatively in the multivariate logistic regression model after adjusting for covariates. Age >40 years increased the risk of intraoperative leakage by 2.3 times (OR, 2.3; 95% CI, 1.2-4.6; p = 0.01). The rate of postoperative anastomotic stricture was the same among patients detected with an intraoperative leak (5.4%) and those without (5.6%; p = 0.934).

CONCLUSIONS

Endoscopic evaluation of the GJ is a sensitive and reliable technique for demonstrating anastomotic integrity and preventing postoperative morbidity after gastric bypass. Age >40 years was identified as an independent risk factor for intraoperative leak in this series.