Reduction in anastomotic strictures using bioabsorbable circular staple line reinforcement in laparoscopic gastric bypass

Effect of Biologic Material Reinforcement on Surgical Anastomosis After Gastrectomy-A Pilot Study

Background: Acellular dermal matrix is a biologic material derived from the skin of human cadaveric donors. It has been used successfully in the past to reduce complications in breast surgery and hernia repair. This investigation was aimed at assessing the feasibility of using acellular dermal matrix to support the anastomosis after gastrectomy with the aim of reducing anastomotic site leakage complications. Methods: Patients were randomly assigned to standard anastomotic reconstruction (control arm) or anastomotic reconstruction with acellular dermal matrix reinforcement (intervention arm). Surgical outcomes related to anastomotic complications were collected. Because actual anastomotic leaks found on imaging studies are infrequent and thus require a very high number of patient recruitment to detect statistically significant difference between the two groups, in this pilot investigation other clinical and laboratory measures that have been shown to correlate to or predict anastomotic leaks were also collected. Each surgical outcome was compared. Results: A total of 94 patients (intervention arm: 50, control arm: 44), were included in the analysis. Two patients in the control arm (4.55%) and one patient in the intervention arm (2.00%) experienced anastomotic leakage (p = 0.598), a difference without statistical significance. However, average postoperative C-reactive protein (CRP) levels and NUn scores, both of which have been shown to reflect likelihood of progressing to anastomotic leakage, were significantly lower for the intervention arm. The control arm showed an average CRP level of 128.77 mg/dL (SD: 97.08) while the intervention arm showed 77.38 mg/dL (SD: 49.08, p = 0.049). Conclusions: Leakage rate reduction with acellular dermal matrix reinforcement of anastomotic site was not detected in this investigation. However, postoperative inflammation levels and numerical predictors of anastomotic leakage development were significantly lower with acellular dermal matrix reinforcement of surgical anastomosis. This finding is worthy of further investigation, as reduction of inflammation with anastomotic site reinforcement is a novel finding, and more in-depth research may lead to discoveries on the physiologic role of the surgical anastomosis in post-gastrectomy patients. In addition, lower CRP and NUn scores for the intervention arm suggest potential for larger studies to detect reduction in clinical leak rates after acellular dermal matrix reinforcement.

Is it the technique or wound protection that is key to reducing wound infections in Roux-en-Y gastric bypass procedures?

INTRODUCTION

An unusually high surgical site infection (SSI) rate after Roux-en-Y gastric bypass (RYGB) was noted on routine outcomes review. Surgeon A, who had a rate of 8.9%, utilized the transoral technique (passage down esophagus into gastric pouch) for anvil insertion for the circular-stapled gastrojejunostomy. By comparison, SSI rate was 0% for Surgeon B, who inserted anvil transabdominally (direct passage into stomach via gastrotomy) and used wound protection (wound protector and plastic drape over stapler). We sought to determine if it was the technique for anvil insertion (transoral or transabdominal) or use of wound protection that could help reduce SSIs.

METHODS

In mid-2017, Surgeon A added wound protection (wound protector and plastic drape over stapler) to the transoral technique to minimize oral flora wound contamination. Surgeon B made no changes. In this study, wound-related outcomes are examined, comparing patients who underwent surgery before (Group 1) versus after (Group 2) this intervention. Statistical analysis performed utilizing t tests and Chi square analysis; p < 0.05 considered significant.

RESULTS

Three hundred and thirty-three patients underwent RYGB. Group 1 consisted of 182 patients over 17 months; 151 patients over 13 months were in Group 2. Groups were similar in age, BMI, gender, and prevalence of diabetes. There was a decrease in SSIs between Group 1 and Group 2 (5 vs. 0, p = 0.04). 11 wound complications occurred in Group 1 (5 SSIs, 4 seromas and 2 hematomas); whereas 2 wound complications occurred in Group 2 (1 seroma and 1 hematoma); decrease from 6 to 1.3%, p = 0.03.

CONCLUSIONS

This study demonstrates that changing technique can lead to best outcomes. There was a dramatic reduction of wound complications and complete elimination of SSIs with a change in operative technique. The higher risk of SSI with the transoral anvil insertion when preforming a circular-stapled anastomosis can be mitigated with use of wound protection.

Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear.

OBJECTIVE

The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique.

SETTING

University Hospital, France.

METHODS

From November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures.

RESULTS

There was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24-146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant (P< .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia.

CONCLUSIONS

A significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.