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Khalayleh H, Pines G, Imam A, Sapojnikov S, Buyeviz V, Mavor E. Anastomotic Stricture Rates Following Roux-en-Y Gastric Bypass for Morbid Obesity: A Comparison Between Linear and Circular-Stapled Anastomosis. J Laparoendosc Adv Surg Tech A 2018; 28:631-636. [DOI: 10.1089/lap.2017.0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Harbi Khalayleh
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
| | - Guy Pines
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ashraf Imam
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
| | - Shimon Sapojnikov
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
| | - Victor Buyeviz
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
| | - Eli Mavor
- Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University School of Medicine, Jerusalem, Israel
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Abstract
PURPOSE Mechanical gastro-intestinal anastomosis using stapler is a critical step in laparoscopic Roux-en-Y gastric bypass (RYGB). To date the effect of the direction of staples on anastomotic leak has not been investigated. The study aim was to investigate the impact of the direction of staples on the integrity of the gastro-jejunal anastomosis. MATERIALS AND METHODS Eight gastro-jejunostomy (GJ) models were performed using porcine stomach and small intestine. Specimens were divided into group A where the cartridge was in the gastric lumen with the anvil in the jejunal lumen and vice versa in group B. Enterotomy was closed and gastric and jejunal ends were stapled off. Burst pressure (BP) was measured by infusion of methylene blue saline into the GJ model until leak occurred. Site of leak, BP, and total volume (TV) infused were recorded. Compliance (C) was calculated from the equation ΔTV/ΔBP. RESULTS The BP was greater in group A compared to group B (18 mmHg (range 15-25) versus 11 mmHg (range 8-15); p = 0.045) despite similar TV between the groups 60.00 mL (range 55.00-65.00) versus 51.25 mL (range 40.00-60.00); p = 0.11). The compliance did not significantly differ between groups A and B (6.38 mL/mmHg (range 4.34-8.59) versus 5.61 mL/mmHg (range 3.93-7.21); p = 0.48). CONCLUSION BP recorded when the stapler cartridge was introduced in the gastric lumen was higher than when it was introduced from the jejunal lumen. The lack of difference in compliance between groups suggests that the difference in BP was due to the difference in the direction of staples.
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Improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation. Surg Obes Relat Dis 2017; 14:16-21. [PMID: 29108894 DOI: 10.1016/j.soard.2017.09.532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/20/2017] [Accepted: 09/26/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Few studies have investigated the burst pressure of side-to-side anastomoses comparing different stapling devices that are commercially available. OBJECTIVES We conducted side-to-side anastomoses with a variety of staplers and compared burst pressure in the crotch of the anastomoses. SETTING Nagoya City East Medical Center. METHODS We conducted side-to-side anastomoses with 9 staplers with different shapes and forms. Fresh pig small intestines were used. A side-to-side anastomosis was performed between 2 intestine specimens using a linear stapler. The burst pressure of the anastomosis was recorded. RESULTS In total, 45 staplers were used for this experiment. The site of leakage in all cases was the crotch. Regarding the influence of the number of staple rows, the burst pressure in 3-row staplers was significantly higher than in 2-row staplers. With regard to the relationship between staple height and burst pressure, staples with a height slightly shorter than the intestinal thickness showed the highest burst pressure. In a comparison of staplers with uniform staple heights and stamplers with staples of 3 different heights, the latter had significantly lower burst pressures. Neoveil significantly increased the burst pressure in the crotch and contributed to the highest burst pressure of all the staplers used in this experiment. CONCLUSIONS In this experiment, we defined the important factors that influence burst pressure at the crotch of a stapled, side-to-side anastomosis. These factors include the number of staple rows, the height of the staple compared with the thickness of the tissue, uniformity of staple height, and reinforcement of the staple line. In any surgical case requiring intestinal anastomosis, selection of a stapler is a critical step.
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Ng CSH, Pickens A, Siegel JM, Clymer JW, Cummings JF. A novel narrow profile articulating powered vascular stapler provides superior access and haemostasis equivalent to conventional devices†. Eur J Cardiothorac Surg 2015; 49 Suppl 1:i73-8. [PMID: 26464450 PMCID: PMC4711582 DOI: 10.1093/ejcts/ezv352] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/03/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Current endoscopic transection devices are not optimized to meet the unique challenges posed by the task of vessel transection in difficult-to-access locations within the pleural cavity. The ECHELON FLEX™ powered vascular stapler (PVS) has been designed with four rows of staples instead of six, to decrease its size and enable more precise placement on fragile pulmonary vessels, using a narrower anvil than other commercially available transecting devices. This study was performed to determine whether the reduced number of staple rows affects haemostasis, and to assess surgeons' initial impression of the smaller stapler during in vivo usage. METHODS The new four-row stapler was compared with commercially available six-row articulating staplers via expert graders using a validated scale of haemostasis in vivo after application on porcine gastroepiploic pedicles and other thin- and thick-walled vessels. The new stapler was then compared with current products by practising thoracic surgeons (n = 27) during in vivo usage of simulated pulmonary procedures in a porcine model. The surgeons were also surveyed on the key attributes of the four-row stapler in relation to the six-row predicates. RESULTS Haemostasis evaluated on an ordered scale was clinically equivalent between the test and predicate staplers, and was deemed acceptable for all thin- and thick-vascular tissue applications. Surgeons found no difference in haemostasis between the four- and six-row staplers (P = 0.486), and judged the four-row stapler superior in terms of access, reduced need for dissection, reduced stress of surgeon and precise control (P < 0.001 for all). CONCLUSIONS The new ECHELON FLEX™ PVS provides haemostasis equivalent to six-row staplers. With a smaller anvil, narrower shaft and wider angle of articulation, the PVS demonstrated improved access capability for pulmonary vessel procedures.
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Affiliation(s)
- Calvin S H Ng
- The Chinese University of Hong Kong, Hong Kong, China
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Abstract
Background
The objective of this study was to evaluate the safety and efficacy of a novel 5-mm laparoscopic linear stapler in clinical gastrointestinal surgical applications. Methods
A prospective, single-arm study with an open enrollment of subjects requiring stapling of the gastrointestinal (GI) tract was performed. The study endpoints were the number of complications and technical failures associated with the use of a novel stapler when compared to similar events with conventional staplers as described in the medical literature. Results Seven centers enrolled 160 subjects, 150 of which were followed up to at least 30 days postoperatively. Intraoperative success: In 423 deployments, there were two staple line leaks and five staple line bleeds, all of which were intraoperatively resolved. In addition, incomplete staple lines were noted as a result of user error (n = 15) or device-related issues (n = 22), all of which were immediately resolved and none of which resulted in a complication or a change of the surgical procedure. Late outcomes: A total of 13 surgical complications in 160 patients were related to a GI transection or anastomosis, 12 of which related to a hand-sewn anastomosis or use of other commercially available staplers. One event (1/153, 0.065 %) on POD 1, involving bleeding of the staple line, was felt to be related to the use of the new stapler. Conclusion The study confirmed that the new device was user-friendly (9 % incidence of problems firing the device), reliable (3 % device failures) and safe (<1 % complication rate related to the stapler). Based on these results, it would seem that this new 5-mm stapler is a safe and effective alternative to standard 12-mm staplers.
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Zellmer JD, Mathiason MA, Kallies KJ, Kothari SN. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg 2014; 208:903-10; discussion 909-10. [DOI: 10.1016/j.amjsurg.2014.08.002] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/05/2014] [Accepted: 08/11/2014] [Indexed: 02/07/2023]
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Medbery RL, Coefield R, Patel AD, Pettitt BJ, Singh A, Srinivasan JK, Woods K, Davis SS. Endoscopic Management of Gastrojejunostomy Strictures: One Institution's Approach. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rachel L. Medbery
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Coefield
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ankit D. Patel
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Barbara J. Pettitt
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Arvinpal Singh
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Kevin Woods
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - S. Scott Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Sozutek A, Colak T, Dag A, Olmez T. Comparison of standard 4-row versus 6-row3-D linear cutter stapler in creation of gastrointestinal system anastomoses: a prospective randomized trial. Clinics (Sao Paulo) 2012; 67:1035-8. [PMID: 23018300 PMCID: PMC3438243 DOI: 10.6061/clinics/2012(09)09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 05/10/2012] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This prospective study was conducted to compare the clinical outcomes of a 6-row 3-D linear cutter with the standard 4-row linear cutter in patients who underwent elective gastrointestinal surgery anastomosis. METHOD Patients who underwent elective open gastrointestinal surgery that included stapled anastomosis using a linear cutter (Proximate®, Ethicon Endo-Surgery, Cincinnati, OH) between January 2011 and May 2011 were included in the study. The patients were randomly assigned to two groups according to the linear cutter that was used in the surgery: the standard 4-row cutter (the S group) or the new 6-row cutter (the N group). The groups were compared based on the patient demographic data, the laboratory parameters, the preoperative diagnosis, the surgery performed, the operation time, intra-or postoperative complications, the time to oral tolerance and the length of the hospital stay. RESULTS The S group included 11 male and nine female patients with a mean age of 65 ± 12 (35-84) years, while the N group included 13 male and eight female patients with a mean age of 62 ± 11 (46-79) years (p =0.448, p = 0.443, respectively). Anastomotic line bleeding was observed in eight (40%) patients in the S group and in one (4.7%) patient in the N group (p = 0.006). Dehiscence of the anastomosis line was observed in two (10%) patients in the S group and none in the N group (p =0.131). Anastomotic leakage developed in three (15%) patients in the S group and in one (4.7%) patient in the N group (p = 0.269). The mean hospital stay was 12.65 ± 6.1 days in theS group and 9.52 ± 2.9 days in the N group (p = 0.043). CONCLUSION The 6-row 3-D linear cutter is a safe and easily applied instrument that can be used to create anastomoses in gastrointestinal surgery. The new stapler provides some usage benefits and is also superior to the standard linear cutter with regard to anastomotic line bleeding.
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Affiliation(s)
- Alper Sozutek
- Department of Gastroenterological Surgery, Mersin University Medical Faculty, Mersin, Turkey.
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Salgado W, Rosa GV, Nonino-Borges CB, Ceneviva R. Prospective and Randomized Comparison of Two Techniques of Staple Line Reinforcement During Open Roux-en-Y Gastric Bypass: Oversewing and Bioabsorbable Seamguard®. J Laparoendosc Adv Surg Tech A 2011; 21:579-82. [DOI: 10.1089/lap.2010.0469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Wilson Salgado
- Department of Surgery and Anatomy, Clinical Hospital, Faculty of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Guilherme Vianna Rosa
- Department of Surgery and Anatomy, Clinical Hospital, Faculty of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Carla Barbosa Nonino-Borges
- Nutritional Division of the Department of Medical Clinic, Clinical Hospital, Faculty of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Reginaldo Ceneviva
- Department of Surgery and Anatomy, Clinical Hospital, Faculty of Medicine, University of São Paulo, Ribeirão Preto, Brazil
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Finks JF, Carlin A, Share D, O'Reilly A, Fan Z, Birkmeyer J, Birkmeyer N. Effect of surgical techniques on clinical outcomes after laparoscopic gastric bypass--results from the Michigan Bariatric Surgery Collaborative. Surg Obes Relat Dis 2010; 7:284-9. [PMID: 21126927 DOI: 10.1016/j.soard.2010.10.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 09/27/2010] [Accepted: 10/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND The techniques used with laparoscopic gastric bypass (LGB) and their association with patient outcomes remain largely unexplored. METHODS We analyzed the data from the Michigan Bariatric Surgery Collaborative, which maintains a state-wide prospective clinical registry of bariatric surgery patients. Participating surgeons were surveyed regarding their use of specific techniques during LGB. The survey data were linked with the registry data from patients undergoing LGB from June 2006 to January 2010. The gastrojejunostomy technique and the use of staple-line reinforcement were evaluated for their effects on patient outcomes. RESULTS During the study period, 9904 patients underwent LGB. A total of 44 surgeons (86%) completed the survey. When performing gastrojejunostomy, most surgeons used a circular stapler (CS) technique (66%), followed by the hand-sewn (HS) (18%) and linear stapler (LS) (16%). Also, 48% of surgeons reported using staple-line buttressing when creating the gastric pouch. The rate of anastomotic leak at the gastrojejunostomy was not affected by the surgical technique (CS .6%, LS .3%, HS .6%, P = .38). However, the CS technique was associated with a greater rate of postoperative hemorrhage (CS 2.9%, LS 1.2%, HS 1.6%, P <.0001) and wound infection (CS 4.7%, LS 1.6%, HS .6%, P <.0001). The use of staple-line reinforcement was associated with a lower rate of postoperative hemorrhage (1.9% versus 2.7%, P = .012). CONCLUSION With LGB, the use of the CS technique was associated with greater rates of postoperative hemorrhage and wound infection than the use of the LS or HS technique. Furthermore, the use of staple-line reinforcement was associated with a reduction in the rates of postoperative hemorrhage.
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Affiliation(s)
- Jonathan F Finks
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Ryskina KL, Miller KM, Aisenberg J, Herron DM, Kini SU. Routine management of stricture after gastric bypass and predictors of subsequent weight loss. Surg Endosc 2009; 24:554-60. [PMID: 19585070 DOI: 10.1007/s00464-009-0605-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 05/11/2009] [Accepted: 06/16/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss. METHODS Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age +/-5 years, gender, and preoperative body mass index (BMI +/- 5). Patients with at least 6 months of follow-up assessment were included in the study. RESULTS Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 +/- 10 years (range, 22-66 years). The mean preoperative BMI was 47.0 +/- 5.4 kg/m(2) for the case group and 46.6 +/- 5.5 kg/m(2) for the control group (p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 +/- 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects (p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively (p = 0.004 and p < 0.001, respectively). CONCLUSIONS Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes.
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Affiliation(s)
- Kira L Ryskina
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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Affiliation(s)
- Deron J Tessier
- Staff Surgeon, Kaiser Permanente Medical Center, Fontana, California, USA
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Balaa FK, Gamblin TC, Tsung A, Marsh JW, Geller DA. Right hepatic lobectomy using the staple technique in 101 patients. J Gastrointest Surg 2008; 12:338-43. [PMID: 17701266 DOI: 10.1007/s11605-007-0236-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 06/30/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Application of linear stapling devices for extrahepatic vascular control in liver surgery has been well-established. However, the technique for use of stapling devices in hepatic parenchymal transection is not well defined. PURPOSE To describe the safety and efficacy of our technique for use of vascular stapling devices in hepatic parenchymal transection during open right hepatic lobectomy is the purpose of this study. METHODOLOGY We reviewed our experience with 101 consecutive open right hepatic lobectomies performed by a single surgeon between January 2003 and July 2006, in which vascular staplers were utilized for the parenchymal transection phase. RESULTS Of the 101 patients who underwent resection, 53 (52%) were female. The mean age was 58 years. Malignant disease was the indication for resection in the majority of patients (88%). Of those with cancer, 78% (69 of 89) had metastatic colorectal cancer, 6% (5 of 89) had metastatic neuroendocrine tumor, 4% (4 of 89) had hepatocellular carcinoma, 4% (4 of 89) had cholangiocarcinoma, and the remaining 8% were other metastatic cancers. Twelve patients (12%) underwent resection for hepatic adenoma or symptomatic benign disease (FNH or hemangioma). Forty-eight patients (48%) underwent a major ancillary procedure at the time of hepatic resection. Thirty-nine patients (39%) had a nonanatomic wedge resection of a left lobe lesion, 27 patients (27%) had one or more lesions treated with radiofrequency ablation (RFA), and 6 patients (6%) were treated with a synchronous bowel resection. The median total operative time was 336 min (range 155-620 min). A Pringle maneuver for temporary vascular inflow occlusion was utilized in all cases, with a median time of 9 min (range 4-17 min). Ten patients (10%) required blood transfusion during surgery or in the postoperative period. The maximum transfusion was 2 U of packed red blood cells (PRBC) in seven patients and 1 U of PRBC in three patients. The mean nadir postoperative hematocrit was 28.2. All patients with malignant disease had tumor-free margins at the completion of the procedure. The average hospital length of stay was 6.0 days. One patient (1%) developed a clinically significant bile leak requiring a postoperative endoscopic retrograde cholangiography (ERCP). No patient required reoperation. The 30 and 60-day postoperative survival was 100%. CONCLUSION These findings indicate that application of vascular stapling devices for parenchymal transection in major hepatic resection is a safe technique, with low transfusion requirements and minimal postoperative bile leak. The technique allows for rapid transection of the entire right hepatic lobe in under 10 min. Short video clips of the technique will be demonstrated.
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Affiliation(s)
- Fady K Balaa
- UPMC Liver Cancer Center, Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Hoffman AB, Powers CJ, Geiss AC. The use of a synthetic mesh to provide port site fixation during laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2007; 2:669. [PMID: 17138241 DOI: 10.1016/j.soard.2006.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 09/13/2006] [Indexed: 10/23/2022]
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Fisher BL, Atkinson JD, Cottam D. Incidence of gastroenterostomy stenosis in laparoscopic Roux-en-Y gastric bypass using 21- or 25-mm circular stapler: a randomized prospective blinded study. Surg Obes Relat Dis 2007; 3:176-9. [PMID: 17331806 DOI: 10.1016/j.soard.2006.11.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 11/21/2006] [Accepted: 11/30/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass is the most common bariatric procedure performed in the United States today. The most common early complication after laparoscopic Roux-en-Y is stenosis. No randomized studies have compared the effect of the different staplers on the incidence of stenosis or on long-term weight loss. We compared the anastomoses performed with the two sizes of circular stapler in common use. METHODS A total of 200 patients were randomized to undergo 21-mm (n = 100) or 25-mm (n = 100) circular stapled gastroenterostomy after induction of anesthesia. No other differences were allowed in the operative technique. Stenosis was defined as patient complaints of dysphagia leading to endoscopy within 10 weeks of surgery, in which a 9-mm diameter endoscope would not pass through the gastroenterostomy without dilation. RESULTS Of the 200 patients, 19 patients in the 21-mm group and 8 in the 25-mm group underwent endoscopy for symptoms (P = 0.027). Of the 19 and 8 patients, 17 and 7, respectively, had measurable stenosis at endoscopy (p = 0.035). Patients with a 21-mm anastomosis developed symptoms an average of 4.8 +/- 1.2 weeks after surgery, and those with a 25-mm anastomosis developed symptoms an average of 8.9 +/- 3.8 weeks postoperatively (P <0.001). CONCLUSIONS We found a significant difference in the stenosis rate between the 21-mm and 25-mm circular stapled anastomoses in laparoscopic Roux-en-Y gastric bypass. The 21-mm staplers led to significantly more endoscopies than did the 25-mm staplers. Symptoms leading to endoscopy occurred significantly later with use of a 25-mm stapler than after a 21-mm stapler.
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