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Kaijser MA, van Ramshorst GH, Emous M, Veeger NJGM, van Wagensveld BA, Pierie JPEN. A Delphi Consensus of the Crucial Steps in Gastric Bypass and Sleeve Gastrectomy Procedures in the Netherlands. Obes Surg 2018; 28:2634-2643. [PMID: 29633151 PMCID: PMC6132743 DOI: 10.1007/s11695-018-3219-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands. METHODS After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps. RESULTS Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively. Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach's alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy. CONCLUSIONS The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures.
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Affiliation(s)
- Mirjam A. Kaijser
- University of Groningen, University Medical Centre Groningen, Post Graduate School of Medicine, Groningen, The Netherlands
- Medical Centre Leeuwarden, Department of Surgery, Leeuwarden, The Netherlands
| | - Gabrielle H. van Ramshorst
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Marloes Emous
- University of Groningen, University Medical Centre Groningen, Post Graduate School of Medicine, Groningen, The Netherlands
| | - Nic J. G. M. Veeger
- Department of Epidemiology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bart A. van Wagensveld
- QURO Obesity Centers – Middle East, Dubai, United Arab Emirates
- Department of Surgery, OLVG West, Amsterdam, The Netherlands
| | - Jean-Pierre E. N. Pierie
- University of Groningen, University Medical Centre Groningen, Post Graduate School of Medicine, Groningen, The Netherlands
- Medical Centre Leeuwarden, Department of Surgery, Leeuwarden, The Netherlands
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Chen J, Miller M, Ibele A, Morrow E, Glasgow R, Volckmann E. Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass. Obes Surg 2018; 28:3352-9. [PMID: 30030727 DOI: 10.1007/s11695-018-3394-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB. METHODS In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher's exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student's t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities. RESULTS Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs. CONCLUSION Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.
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Giordano S, Salminen P, Biancari F, Victorzon M. Linear stapler technique may be safer than circular in gastrojejunal anastomosis for laparoscopic Roux-en-Y gastric bypass: a meta-analysis of comparative studies. Obes Surg. 2011;21:1958-1964. [PMID: 21909866 DOI: 10.1007/s11695-011-0520-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The technique of choice for gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity is controversial. We performed a meta-analysis comparing linear versus circular stapler technique to evaluate this issue. A systematic literature search was performed. Primary outcomes were gastrojejunal leak and stricture. Secondary outcomes were operative time, length of hospital stay, post-operative bleeding, wound infection, marginal ulcers and estimated weight loss. Eight studies involving 1,321 patients were retrieved and included in the present study. A significantly decreased risk of GJ stricture was observed after using linear versus circular stapler (RR, 0.34; 95% CI, 0.12-0.93; p = 0.04). Wound infection risk (RR, 0.38; 95% CI, 0.22-0.67; p = 0.0008) and operative time (MD, -24.18; 95% CI, -35.31, -13.05; p < 0.0001) were significantly reduced by using linear stapling. No significant differences were observed in the other outcome end-points. The use of the linear stapler compared with circular stapler for GJ during LRYGB for morbid obesity may be associated with a reduced risk of anastomosis stricture and wound infection, as well as with a shorter operative time.
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Abstract
Over the past 20 years bariatric surgery proved to be a valid treatment for reduction and elimination of obesity-related diseases and long-term sustainable weight loss. Minimally invasive or laparoscopic techniques such as laparoscopic Roux-en-Y (LRNY) have replaced open procedures. Many factors play important roles in the small intricacies and variations of the procedure, chief of which is the creation and size of the gastrojejunostomy. Regardless of the variations in technique, the LRNY remains the gold standard for the surgical treatment of clinically severe or morbid obesity, with relatively low morbidity and mortality.
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Affiliation(s)
- Myron S Powell
- Department of General Surgery, Wake Forest University School Of Medicine, Winston-Salem, NC 27157, USA
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Fernández-Meré LA, Alvarez-Blanco M. [Use of a McGrath videolaryngoscope to release an autosuture stapler caught in the esophageal sphincter]. Rev Esp Anestesiol Reanim 2011; 58:589-591. [PMID: 22279881 DOI: 10.1016/s0034-9356(11)70147-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Bohdjalian A, Langer FB, Kranner A, Shakeri-Leidenmühler S, Zacherl J, Prager G. Circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009; 20:440-6. [PMID: 19856035 DOI: 10.1007/s11695-009-9998-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Accepted: 10/05/2009] [Indexed: 12/25/2022]
Abstract
BACKGROUND Different surgical techniques have been developed for the gastrojejunostomy (GJS) in laparoscopic Roux-en-Y gastric bypass (LRYGBP) with the anastomosis performed in a circular-stapled, linear-stapled, or totally hand-sewn way. No technique seems superior to the other as no consistent data on weight loss or complication rates were described. METHODS A matched-pair study was conducted including a total of 150 patients, who underwent primary antegastric, antecolic LRYGBP between August 2003 and February 2007. Early weight loss and the incidence of GJS strictures or leaks and wound infections were compared between circular-stapled anastomosis (CSA) and linear-stapled anastomosis (LSA). Both groups were matched for age, sex, and body mass index. RESULTS Excess weight loss at 3 months was slightly better with the CSA (p = 0.002) and comparable thereafter. Percentage of excess weight loss at 6, 12, and 24 months was 55.9 +/- 17.5% vs. 51.2 +/- 14.5%, 69.5 +/- 20.9% vs. 71.4 +/- 22.6%, and 70.8 +/- 22.4% vs. 73.2 +/- 23.4%, respectively (CSA vs. LSA). Strictures at the GJS were found only in the CSA group (n = 4), and leaks were found in one patient of the CSA group. More wound infections were observed in patients of the CSA group (ten vs. one). CONCLUSIONS CSA and LSA lead to comparable early weight loss in LRYGB. Thus, the technique is the surgeon's choice. In CSA, a higher incidence of GJS strictures and wound infections was observed. As weight regain following LRYGBP is commonly observed after at least 3 years, a longer follow-up is needed to compare the incidence of weight regain in circular- vs. linear-stapled GJS.
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Affiliation(s)
- Arthur Bohdjalian
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
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Steffen R, Guweidhi A, Metzger A, Z'graggen K. Advances in circular stapling techniques for gastric bypass: the circular stapler introducer. Obes Surg 2009; 19:504-7. [PMID: 19159987 DOI: 10.1007/s11695-009-9799-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 01/05/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Modern laparoscopic bariatric surgery relies strongly on stapling devices and the perfection of the anastomotic technique is at the core of the patient's safety. METHODS Circular stapler anastomosis is a common technique for performing gastro-jejunostomy in gastric bypass surgery. In obese patients, transabdominal circular stapler introduction can be challenging and associated with morbidity. To overcome these technical obstacles, we have developed a new device, circular stapler introducer (CSI) to assist both the abdominal wall passage of the circular staplers and its introduction into the jejunum. RESULTS The CSI facilitates the insertion of the circular stapler not only into the abdomen but also into the jejunum enhancing safety and swiftness of laparoscopic Roux-en-Y gastric bypass. CONCLUSIONS Our innovative CSI device facilitates this part of the operation significantly and makes the performance of bariatric surgery more convenient.
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Affiliation(s)
- Rudolf Steffen
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Switzerland.
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Chavarriaga LF, Cook MW, White B, Jeansonne L, Gletsu N, Parker CB, Sweeney J, Davis SS, Lin E. Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost. Obes Surg 2008; 20:846-50. [PMID: 19015931 DOI: 10.1007/s11695-008-9761-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 10/29/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure. METHODS We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD. RESULTS Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different. CONCLUSION The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.
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Affiliation(s)
- Luis Felipe Chavarriaga
- Department of Surgery, Minimally Invasive Surgery, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA 30322, USA.
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Alasfar F, Sabnis A, Liu R, Chand B. Reduction of circular stapler-related wound infection in patients undergoing laparoscopic Roux-en-Y gastric bypass, Cleveland clinic technique. Obes Surg 2008; 20:168-72. [PMID: 18839083 DOI: 10.1007/s11695-008-9708-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 09/11/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Circular-stapled anastomosis with trans-oral anvil insertion for the creation of the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with frequent infections at the abdominal wall site where the circular stapler is inserted. METHODS Patients who underwent routine LRYGBP over a 1.5-year period at The Cleveland Clinic Foundation without any concomitant procedures were included. After our initial experience with circular-stapled anastomosis-related wound infections, we implemented measures to reduce the infection rate. Prevention measures included chlorhexidine "swish and swallow," a plastic barrier device over the stapler, wound irrigation, loose skin approximation, and placement of loose packing. We compared wound infection rates in patients before ("no prevention") and after ("prevention") implementing these measures. RESULTS Ninety-one patients with mean age of 42 years and average body mass index of 48 kg/m(2) underwent laparoscopic Roux-en-Y gastric bypass. The infection rate was 30% among the "no prevention" (n = 10) group and 1% in the "prevention" (n = 81) group (p < 0.05). CONCLUSIONS Trocar site infection related to the circular-stapled anastomosis technique can be significantly reduced with simple prevention measures.
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Affiliation(s)
- Fahad Alasfar
- Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait,
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Shang E, Hasenberg T, Magdeburg R, Keese M, Post S, Weiner R. RETRACTED ARTICLE: First Experiences with A Circular Stapled Gastro-Jejunostomy by a New Transorally Introducible Stapler System in Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2009; 19:230-6. [DOI: 10.1007/s11695-008-9661-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 08/04/2008] [Indexed: 11/24/2022]
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Madan AK, Harper JL, Tichansky DS. Techniques of laparoscopic gastric bypass: on-line survey of American Society for Bariatric Surgery practicing surgeons. Surg Obes Relat Dis 2007; 4:166-72; discussion 172-3. [PMID: 18069071 DOI: 10.1016/j.soard.2007.08.006] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 07/12/2007] [Accepted: 08/13/2007] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Atul K Madan
- Minimally Invasive Surgery Section, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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