Anastomotic Stricture Rates Following Roux-en-Y Gastric Bypass for Morbid Obesity: A Comparison Between Linear and Circular-Stapled Anastomosis

Long-Term Results of Linear Versus Circular Stapled Gastrojejunostomy in Gastric Bypass Surgery: A Propensity Score-Adjusted Analysis of Weight Loss and Morbidity

BACKGROUND

Different techniques are used to create a gastrojejunal anastomosis (GJ) in laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares long-term weight loss and technique-related morbidity between circular (CSA) GJ and linear (LSA) stapled GJ.

METHODS

The clinical data of LRYGB patients prospectively registered in a database were retrospectively analyzed. The primary endpoints were long-term excess weight loss (EWL) and excess BMI loss (EBL). The risk factors were adjusted via propensity score matching (PSM), and the long-term morbidity rates of the procedures were compared as time-to-event-data using hazard ratios (HR).

RESULTS

Two hundred forty-three patients underwent surgery between 2012 and 2014 (CSA n = 109; LSA n = 134). No significant differences in weight development were shown during 6 years postoperatively between CSA and LSA. A mixed effects regression analysis before and after PSM revealed that CSA performed better than LSA after 6 years (potentially biased by low follow-up rates for this period). CSA was associated with higher overall morbidity (LSA 26.1% vs. CSA 38.8%, HR = 1.58, p = 0.048), incisional hernia (LSA 0.7% vs. CSA 6.4%, HR = 10.0, p = 0.006), and GJ stenosis rates (LSA 0% vs. CSA 17.4%, p < 0.001). LSA was associated with marginal ulcers (LSA 8.2% vs. CSA 0.9%, HR = 5.5, p = 0.012).

CONCLUSIONS

Marginal ulcers have been linked to LSA, while CSA has been associated with higher rates of overall morbidity, stenosis of the GJ, and incisional hernia. No difference terms of weight loss were observed between the CSA and LSA groups during the initial six postoperative years. After 6 years, CSA may offer benefits in terms of sustained weight loss; however, the clinical relevance of these differences appears minimal.

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021

INTRODUCTION

Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm.

METHODS

Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed.

RESULTS

A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not.

CONCLUSIONS

Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Linear and circular stapled gastrojejunal anastomoses in Roux-en-Y gastric bypass: stomal diameter at onset and at long-term follow-up

BACKGROUND

In the laparoscopic Roux-en-Y gastric bypass procedure, the gastrojejunal stoma is constructed with either a circular (CSD) or a linear stapling device (LSD). The diameter of the stoma following stapling with the 21 mm CSD is expected to be approximately 12 mm (diameter of the anvil). Measuring the stoma diameter after linear stapling is a little more complex since the remaining opening in the linear anastomosis is closed by hand. The aim of this prospective randomized study was to follow up on changes in the diameter of gastrojejunal stomata after laparoscopic Roux-en-Y gastric bypass using either a CSD or an LSD between that at construction and at a long-term follow-up of 12-72 months later.

METHODS

Twenty patients were randomly assigned to gastrojejunostomy with either a 21 mm CSD or a 45 mm LSD. Directly after completion of the surgery, the diameter of the gastrojejunal stoma was measured using a Fogarty occlusion catheter and again at follow-up 12-72 months later.

RESULTS

Five patients were lost for follow-up, and 15 patients remained. The mean diameter of the CSD stomata at construction was 19.3 ± 5.3 mm (mean ± SD) and increased to 26.4 ± 6.6 mm at follow-up after a mean of 46 months (P = 0.02). The corresponding figures for the LSD stomata were 26.2 ± 4.1 mm, increasing to 32.7 ± 3.0 mm also after a mean follow-up of 46 months (P = 0.03).

CONCLUSIONS

The mean diameter of the circular stapled gastrojejunostomy stomata at construction was 20 mm, that is, considerably larger than the 12 mm expected. After a mean of 5 years, the mean diameter had increased by 37%. The mean diameter of the linear stapled stomata increased by 25%.

Linear Versus Circular Laparoscopic Gastrojejunal Anastomosis of Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis of 22 Comparative Studies

PURPOSE

To compare the rate of complications of linear versus circular gastrojejunal anastomosis of laparoscopic Roux-en-Y gastric bypass.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library databases was carried out using the terms "laparoscopic," "circular," "linear," "anastomosis," "gastric bypass" in accordance to PRISMA guidelines. Only original articles in English language comparing linear versus circular anastomosis were included. No temporal interval was set. Outcome measures were wound infection, bleeding, marginal ulcer, leak, and stricture. Pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the I2 statistic. Funnel plots were used to detect publication bias.

RESULTS

Twenty-two articles (7 prospective and 15 retrospective) out of 184 retrieved papers were included in this study. The pooled analysis showed a reduced odd of wound infection and bleeding after linear anastomosis. Likelihood of marginal ulcer, leak, and stricture was similar after the 2 techniques. Wound infection was reported in 15 studies (OR, 0.17; 95% CI, 0.06-0.45; P=0.0003; I2=91), bleeding in 9 (OR, 0.45; 95% CI, 0.34-0.59; P=0.00001; I2=6) marginal ulcer in 11 (OR, 0.61; 95% CI, 0.26-1.41; P=0.25; I2=65), leaks in 15 (OR, 0.61; 95% CI, 0.21-1.67; P=0.34; I2=83) and stricture in 18 (OR, 0.48; 95% CI, 0.23-1.00; P=0.05; I2=68).

CONCLUSION

Laparoscopic RYGB can be safely performed both with circular and linear staplers. Rates of wound infection and bleeding were significantly lower after linear gastrojejunal anastomosis.

Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review

BACKGROUND

There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.

METHODS

PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.

RESULTS

Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.

CONCLUSION

This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Gastrojejunal Anastomotic Technique. Does It Matter? Weight Loss and Weight Regain 5 Years After Laparoscopic Roux-en-Y Gastric Bypass

Purpose

The gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB) can be constructed by hand sewn (HSA), linear (LSA) and circular (CSA) stapler technique. They are all considered safe; however, it is not known which the best technique is. Short-term follow-up suggest no difference in weight loss or weight regain between them. However, there is no information on these parameters in the long term. Theatre time and cost are other important factors defining the best way to form gastrojejunostomy.

Materials and Methods

In a prospective longitudinal cohort study consecutive patients following primary LRYGB were recruited to a bariatric database in a tertiary care centre. Anastomotic technique, diameter, the length of operations and associated costs, weight loss and weight regain were recorded. Patients were followed up for 5 years.

Results

A total of 385 patients with an initial body mass index of 47.1 kg/m² (35–68) were enrolled to this study. This decreased to 33.3 kg/m² (21–54 kg/m²) after 5 years. There was no difference in %TWL after 3 years, P = 0.296, or 5 years, P = 0.187, between the techniques. The number of patients with weight regain was not different after 3 years, P = 0.224, or 5 years, P = 0.795. All techniques had similar operative time. CSA has a higher material cost. Early anastomotic stricture was more common following HSA; however, the difference was not significant.

Conclusion

Mid-term weight loss and weight regain are not related to anastomotic technique, and there is no difference in operative time associated to them. Circular stapler technique has a higher material cost due to the additional stapler.

Systematic Review and Meta-analysis of Circular- and Linear-Stapled Gastro-jejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7-37.6.; p < 0.0001). No difference was seen concerning leaks or strictures. The relative risk (RR) of leakage after LS was 80% of the risk after CS; however, the 95% confidence interval (CI) showed overlap (0.58-1.11). The RR of anastomotic stricture after LS was 74% of the risk after CS; however, 95% CI (0.52-1.05) showed overlap. Wound infections were less common after LS than after CS; RR was 27% (95% CI 0.21-0.33). Length of stay (LOS) was 0.65 days shorter after LS than after CS (95% CI 0.51-0.78). LS compared with CS results in shorter operative time, less wound infections, and shorter length of stay, but no difference was seen concerning risks of leaks or strictures.