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

Abstract

Background:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective procedure in the management of morbid obesity with variations in outcome, which are technique dependent. Anastomotic stricture remains an important complication. The aim of this study was to assess the long-term outcome of patients undergoing either a linear-stapled anastomosis (LSA) or circular-stapled anastomosis (CSA) with an emphasis on postoperative stricture formation and excess body weight loss (EBWL).

Methods:

Medical records of all patients who underwent bariatric surgery between 2008 and 2013 at a single bariatric surgical center were reviewed. All patients who had a LRYGB were included in the study. Patients were divided in two groups based on stapling technique—LSA and CSA. Patient groups were compared with regard to perioperative complication, EBWL.

Results:

A total of 114 patients were included in the study. There were 51 patients in the LSA group and 63 in the CSA group. No differences were found between the two groups with regard to operative time, hospital stay, or in the EBWL over a 12-month follow-up period. Anastomotic stricture developed in 4 patients, all occurring in the LSA group (7.8%). Three of these patients had undergone successful endoscopic dilatation.

Conclusions:

Both stapling techniques resulted in a similar EBWL during the follow-up period and an acceptable safety profile. Anastomotic stricture rate was slightly higher in the LSA, but this did not affect EBWL.

Introduction

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a proven and sustainably effective surgical weight loss procedure for the treatment of morbid obesity.^1,2 Comparative studies have shown advantage for the LRYGB procedure over restrictive procedures, such as laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB).^3,4 Table 1 shows the leakage and stricture rates for comparative studies of hand-sewn anastomotic (HSA), linear-stapled anastomotic (LSA) and circular-stapled anastomotic (CSA) techniques.^5–17 The majority of trials are retrospective, however, there are two prospective randomized controlled studies.^8,16 Most trials have compared CSAs with LSAs with some trials incorporating a third HSA arm,^{(5,12–16,18} and some specifically comparing LSA with HSA^12,13 or CSA with HSA.¹⁵ Most trial reported results of 21 mm CSA. In this study, we directly compare LSA to 25 mm CSA.

Table 1.

Summary of Comparative Trials Assessing Technique in Laparoscopic Roux-en-Y Gastric Bypass: Comparisons of Postoperative Stricture, Leak, and Wound Infection Rates

Author (year)	Trial type	N	Stricture (%)	Leak (%)	WI (%)
Leyba et al. (2008)⁷	PRCT	LSA (40)	—	—	—
		CSA (40)	4	—	—
Sczepaniak and Owens (2009)⁸	Retro	LSA (100)	—	1	—
	Non-RCT	CSA (124)	12.9	0.8	0.16
Bohdjalian et al. (2010)⁹	Retro	LSA (75)	—	—	1
	Non-RCT	CSA (75)	4	1	10
Giordano et al. (2010)¹⁰	Retro	LSA (41)	4.9	4.9	12.2
	Non-RCT	CSA (30)	13.3	6.7	30
Bendewald et al.(2011)¹¹	Retro	LSA (514)	6	1	—
	Non-RCT	CSA (140)	4.3	—	—
		HSA (181)	6.1	1.1	—
Kravetz et al. (2011)¹²	Retro	LSA (99)	10.1	—	1
	Non-RCT	HSA (123)	4.1	—	1
Jarry et al. (2012)¹³	Retro	LSA (51)	2	2	NS
	Non-RCT	HSA (53)	2	2	NS
Lee et al. (2014)¹⁴	Retro	LSA (142)	5.6	NS	NS
	Non-RCT	CSA (110)	8.2	NS	NS
		HSA (174)	9.7	NS	NS
Abellán et al. (2015)¹⁵	PRCT	CSA (119)	4.3	2.6	11.1
		HSA (119)	2.6	0.8	3.4
Qureshi et al. (2015)¹⁶	Retro	LSA (429)	4.4	0.2	NS
	Non-RCT	CSA (254)	1.1	0.4	NS
		HSA (177)	2.8	—	NS

CSA, circular-stapled anastomosis; HSA, hand-sewn anastomosis; LSA, linear-stapled anastomosis; NS, not stated; PRCT, prospective randomized controlled trial; RCT, randomized controlled trial; Retro, retrospective; WI, wound infection.

Stricture rates are 0.5%–33.3% for HSA, 0%–10.1% for LSA, and between 4% and 16.6% for CSA gastrojejunal anastomosis. The majority of strictures develops within the first 2 months after surgery and is amendable to endoscopic dilatation.^17,19 Leakage rates are also low: 0%–6.6% for HSA, 0%–6.9% for LSA, and 0%–6.6% for CSA. This retrospective analysis assesses the perioperative outcome (with an emphasis on anastomotic stricture) of a nonrandomized cohort of patients undergoing either an LSA or CSA-stapled gastrojejunal anastomosis during LRYGB at a single bariatric center.

Methods

Approval of the Institutional Review Board was obtained. Medical records of all patients who underwent bariatric surgery between March 2008 and November 2013 at a single bariatric surgical center were reviewed.

All patients undergoing bariatric surgery were evaluated by a dedicated multidisciplinary team. All operations were performed by a single surgeon. All patients who had a LRYGB were included in the study. Patients were divided into two groups based on stapling techniques—LSA and CSA. Patient groups were compared with regard to perioperative complications, hospital stay, and excess body weight loss (EBWL).

All patients underwent preoperative smoking cessation counseling, and started on proton pump inhibitors (PPI) postoperatively for at least 3 months. Patients underwent upper gastrointestinal swallow study on the first postoperative day.

Data were collected regarding demographics, hospital stay, and perioperative complication, including gastrojejunal anastomotic strictures (GJS), anastomotic leaks, bleeding, marginal ulceration, and wound infection. Weight loss was expressed as percentage of EBWL based upon Life Tables²⁰ recorded at 6 and 12 months postoperatively. Percentage of EBWL was calculated by dividing the difference between initial body mass index (BMI) and final BMI by the difference between initial BMI and a BMI of 25 kg/m², the upper limit of a normal range BMI.

Patients were followed at the clinic at 1, 4, and 12 weeks and then at 3, 6, 12, and 24 months after surgery. Patients who developed dysphagia, persistent nausea, and vomiting underwent esophagogastroduodenoscopy.

A stricture that was defined as an anastomosis would not accommodate the passage of a 10 mm flexible endoscope in the presence of symptoms within 90 days from surgery. This period was chosen to include all early strictures and to exclude delayed strictures related to marginal ulceration. Strictures were treated by pneumatic balloon dilatation up to 20 mm for 1 minute.

Operative Techniques

All patients received preoperative prophylactic low-molecular-weight heparin and antibiotic prophylaxis. A divided gastroplasty was used in all cases with formation of a 30–50 mL proximal pouch and a 120–150-cm-long antecolic Roux limb for gastro-jejunal anastomosis (GJA) and lineal stapled anastomosis between the alimentary and biliopancreatic limbs distally. The operative field was routinely drained. The choice of anastomotic technique was done at the surgeon's discretion. No specific considerations were employed in selecting the anastomotic technique.

CSA technique

After creation of the gastric proximal pouch, a 25 mm circular end-to-end stapler (EEA) was used to create a CSA (Covidien, Mansfield, MA) with insertion of the anvil via a distal gastrotomy after deployment of a 2/0 PDS purse-string suture. The shaft was introduced through the blind jejunal end. The enterotomy was closed using a linear stapler.

LSA technique

The limbs of a 45 mm Endo GIA stapler (Covidien Co.) are introduced through a gastrotomy and enterotomy with subsequent longitudinal two-layer closure of the enterotomy with 3/0 absorbable suture over a 36Fr bougie.

Upon completion of the anastomosis a nasogastric tube was inserted by the anesthesiologist, the alimentary limb was clamped, and Methylene Blue instilled through the nasogastric tube to rule out an anastomotic leak.

Statistical analysis

Analysis was performed using SPSS software (Chicago, IL). Values for continuous variables are expressed as mean with categorical data being analyzed using Chi-square testing and Fisher's Exact testing where appropriate. Comparisons were made between the groups employing a two-tailed Student's t-test. P values <.05 are considered significant.

Results

A total of 359 patients underwent bariatric procedures during the study period: 230 underwent LSG; LRYGB was performed in 114 patients; 8 patients underwent LAGB placement; and 25 patients underwent LAGB removal, 17 of them with concurrent LRYGB and 1 with LAGB replacement. Of these, 114 patients were included in the study. Male/female ratio was 21/93, with a mean age of 45.9 (19–67 years). Thirty-five percent of patients had previous abdominal surgery. Twenty seven percent of the patients had a prior bariatric surgery (Table 2).

Table 2.

Previous Surgeries of the Patient Cohort Undergoing Bariatric Surgery for Morbid Obesity

	LSA	CSA
Previous abdominal surgery
Appendectomy	6	3
Cholecystectomy	12	10
Gynecologic surgery	3	3
Hernia repair	1	2
Total	22	18
Previous bariatric surgery
LAGB	7	20
SRVG	—	1
LSG	2	1

CSA, circular-stapled anastomosis; LAGB, laparoscopic adjustable gastric band; LSA, linear-stapled anastomosis; LSG, laparoscopic sleeve gastrectomy; SRVG, silastic ring vertical gastroplasty.

There were 51 patients in the LSA group and 63 in the CSA group. Table 3 summarizes the characteristics of the cohort and the EBWL recorded. EBWL was similar between groups at 6 months (64% for LSA versus 54% for CSA, not stated [NS]) or by 12 months follow-up (75% for LSA versus 76% for CSA, NS). There was no difference between the groups with regard to operative time or hospital stay (Table 4).

Table 3.

Comorbidities and Excess Weight Loss of the Cohort

		LSA (%)			CSA (%)
	Total	Total	Males	Females	Total	Males	Females
No. of patients	114	51 (44.7)	5	46	63 (55.2)	16	47
Mean age (years)	45.9	42.2	42.2	42.7	49	50.6	48.5
Mean BMI	43	41.8	40.1	41.9	44	41.9	44.7
EBWL-6 months (%)	57	64	65.5	62.5	53.7	56.8	52.6
EBWL-12 months (%)	75.4	74.9	74.6	75.2	75.9	76	75.8
Comorbidities		Total (%)		LSA (%)		CSA (%)
Diabetes		47 (41.2)		20 (39.2)		27 (42.9)
Hypertensions		59 (51.7)		24 (47.1)		35 (55.6)
Hyperlipidemia		44 (38.6)		14 (27.5)		30 (47.6)
Osteoarthritis		1 (0.87)		—		1 (1.6)
Sleep apnea		10 (8.7)		2 (3.9)		8 (12.7)
Asthma		10 (8.7)		4 (7.8)		6 (9.5)
GERD		16 (14)		6 (11.8)		10 (15.9)
Hiatal hernia		27 (23.6)		11 (21.6)		16 (25.4)

BMI, body mass index; CSA, circular-stapled anastomosis; EBWL, excess body weight loss (%); GERD, gastroesophageal reflux disease; LSA, linear-stapled anastomosis.

Table 4.

Operative Data and Perioperative Complications

	Total	LSA	CSA	P
	116	51	63
Operative time^a	163 (±52)	156 (±49)	169 (±54)	NS
LOS	6.2 (±1.7)	6 (±1.4)	6.4 (±1.9)	NS
Anastomotic leak	3 (2.6%)	2 (3.9%)	1 (1.6%)	NS
Intra-abdominal abscess	2 (1.7%)	1 (2%)	1 (1.6%)	NS
Wound infection	2 (1.7%)	1 (2%)	1 (1.6%)	NS
Upper GI bleed	3 (2.6%)	2 (3.9%)	1 (1.6%)	NS
Bleeding (other)	4 (3.5%)	4 (7.8%)	—	NS
GJ anastomotic stricture	4 (3.5%)	4 (7.8%)	—	P < .05
Marginal ulcer	5 (4.3%)	1 (2%)	4 (6.3%)	NS
Port site hernia	4 (3.5%)	1 (2%)	3 (4.7%)	NS
Internal hernia	4 (3.5%)	1	3 (4.7%)	NS

Minutes, mean.

CSA, circular-stapled anastomosis; GJ, gastro-jejunal; LOS, length of hospital stay (days, mean ± standard deviation); LSA, linear-stapled anastomosis; NS, not stated.

Postoperative complications are summarized in Table 4. Seven patients (6.1%) had undergone reoperation due to perioperative complications. In the LSA group there were 4 cases: 1 for trocar site bleeding, 2 due to an anastomotic leak, and 1 for a combined marginal gastrojejunostomy ulcer and anastomotic stricture. In the CSA group 3 patients underwent reoperation: 1 with a bleeding marginal ulcer, 1 with bleeding from the gastrojejunal anastomotic staple line, and 1 due to internal hernia.

Three patients developed anastomotic leak: 2 patients in the LSA group and 1 in the CSA group. The one in CSA group had a minor leak with no contrast extravasation and was managed conservatively. The 2 patients in the LSA group who developed anastomotic leakage were operated. One of these patients underwent multiple surgeries and subsequently developed an enterocutaneous fistula, which closed after 4 months. Marginal ulceration developed in 4.3% of patients: 4 cases in the CSA group (6.3%) and 1 in the LSA group (2%). All patients were managed successfully with PPI, except for 1 patient who required operative revision for persistent obstructive anastomotic symptoms.

A total of 4 patients developed anastomotic strictures, all in the LSA group (7.8%, P < .05). Three patients were successfully managed with endoscopic pneumatic balloon dilatation. Two patients required a single dilatation, and 1 required three dilatations. All dilatations were performed at 2 months from surgery. One patient with combined stricture and marginal ulcer in this group had previously undergone an unsuccessful sleeve gastrectomy, which was converted to a gastric bypass. A gastro-jejunal (GJ) stricture developed in this patient at 5 months requiring multiple dilatations over a further 6 months with a perforation occurring after one dilatation and necessitating revision of the anastomosis. This patient has had an uneventful outcome.

Wound infection rates were low for both groups (2% for LSA versus 1.6% for CSA, NS).

Discussion

This study compares the short and long-term results of patients with morbid obesity undergoing LRYGB with LSA and CSA techniques. All 4 cases of GJ anastomotic stricture occurred in the LSA-treated group (7.8%, P < .05), but this did not affect long-term EBWL. Most cases (75%) were successfully managed by endoscopic pneumatic balloon dilatation.

The percentage of EBWL in our study was similar to previously reported rates in other studies directly comparing the CSA and LSA techniques^6,9,14; however, in one study by Bohdjalian et al. EBWL was higher during the early postoperative period with LSAs, but a higher GJS rate was reported with the CSA technique.⁹

The LRYGB procedure effectively combines the principles of restriction with malabsorption although weight loss after this procedure, regardless of anastomotic technique, is a complex process. Variability of reports in trials comparing anastomotic techniques reflects patient matching, the standardization of pouch size, and anastomotic size and limb lengths.

Our data are in keeping with published reports concerning the overall rate of early postoperative complications following LRYGB, where the principal morbidity is due to infection of the surgical wound, gastrointestinal bleeding, and anastomotic leak.²¹ Delayed complications include GJS, marginal ulceration, port site hernia, gastric fistula, and small bowel obstruction, and as these later complications may affect weight loss, extended follow-up is required. Our overall wound infection rate was extremely low (2/114; 1.7%). Higher wound infection rates have been reported with CSAs when compared with LSAs, where there is a lack of soft-tissue protection in the left upper quadrant port site on stapler introduction and with removal of the jejunal segment and where there tends to be a longer operative time.^6,9

The focus of our article is on GJS since these contribute to almost half the readmissions of patients in the early postoperative period.²² The incidence of GJS will affect early and delayed weight loss, but is dependent upon the definition of a stricture, the threshold for endoscopy, and the use of an aggressive postoperative management protocol. Symptoms of a GJS typically include dysphagia, an inability to progress to different stages of diet, nausea, vomiting, and/or epigastric pain, although abdominal pain and indigestion in the early postoperative period may frequently be associated with a normal endoscopy.²³ It is likely in our study that the incidence of GJS is underestimated, where patient descriptions of symptoms were used as an indication for endoscopy. This is a particular feature in some patients with a GJS who underreport symptoms with significant weight loss that is perceived by the patient as a desirable outcome. Although this confounding variable could be eliminated by routine standardized endoscopic or radiological assessment of patients with defined criteria, it would result in significant overinvestigation in the majority of patients.

Concerning this point, in a study by Csendes et al.,²⁴ where routine endoscopy was performed 1 month following LRYGB, 29% of asymptomatic cases were noted to have mild anastomotic strictures, although all cases were endoscopically normal on repeat endoscopy at 17 months. The advantages of an early endoscopy policy include an ability for the surgeon to evaluate the gastric pouch, as well as an opportunity to assess the severity of any stricture and to perform dilatation in a single diagnostic and therapeutic intervention. Further longitudinal study designed to assess stoma dilatation will be required beyond one postoperative year to determine the impact of surgical technique on sustained weight loss and upon weight regain.²⁵

Although the numbers are small, our postoperative GJS risk is comparable with other studies, where stricture rates have ranged from 0% up to 33.3%. In many articles, more strictures resulted following CSA use^{5,7–10,14,16,18} than after LSA use,¹¹ although none of these differences appears to be statistically significant. Where stated, for CSAs, a smaller stapler size of 21 mm is more commonly associated with stricture formation^5,7 although strictures have occurred with the larger 25 mm stapler size in some studies.^11,14 Concerning this point, in general, randomized studies comparing a smaller 21 mm with a larger 25 mm stapled anastomosis have shown lower GJS rates with larger anvils,^26,27 although one open-label study by Rondan et al. reported a very low rate of GJS using a 21 mm CSA stapler.²⁸ Two large meta-analyses^21,29 have shown higher GJS rates (ranging from 3% to 16.6%) for CSAs when compared with LSAs (0–10%). Greater stoma sizes have been shown to have a negative impact on weight loss outcomes, although this early effect tends to stabilize by 2 postoperative years^5,27 and is probably more dependent upon the size of the gastric pouch which should be kept under 50 mL capacity.^30,31

The pathogenesis of GJS following LRYGB is multifactorial implicating anastomotic ischemia, excessive scar formation, gastric acid hypersecretion, and the technique of anastomotic construction. One recent study by Ribeiro-Parenti et al. showed a lower GJS rate with retrocolic as opposed to antecolic anastomosis,³² although laparoscopic revision is technically easier if the anastomosis is antecolic. Other technical features which potentially influence the GJS rate depend upon the staple method used, where with CSA there may be benefit from bioabsorbable staple line reinforcement,³³ and with LSA from a six-row as opposed to a four-row staple line deployment.³⁴ Techniques designed to prevent leak, including oversewing of the staple lines, buttressing materials, and surgical glues are all likely to influence the reported GJS rates.³⁵ As all of our cases of GJS occurred with the LSA technique, this may have something to do with the method of closure of the enterotomy angle, where there is potentially a compromise of the anastomosis. Enterotomy closure may be performed either longitudinally (stomach-to-stomach or small bowel-to-small bowel) or transversely (stomach-to-small bowel), where Mueller et al. were able to eliminate strictures with a hand-sewn laparoscopic enterotomy closure technique.³⁶

Further differences in reported GJS rates in stapled cases may be dependent upon the incidence of marginal ulceration and the use of postoperative acid suppression.³⁷ In general, GJS occurs early (within 2 months) with most cases being able to be managed endoscopically, although half the patients will require at least two dilatations.³⁸ Further debate concerns the optimal dilatation technique where rigid Savary-Gilliard dilators appear to provide a more durable result when compared with pneumatic dilatation, but where the lower shear forces of balloons frequently make them the first choice of most units.³⁹ In summary, LRYGB surgery is safe with acceptable weight loss and with no real advantage of one stapling technique over the other for primary and secondary outcome measures. The literature concerning GJS following this procedure is difficult to interpret because of poor patient matching or randomization, nonstandardization of either the operative technique or gastric pouch size, and variability of surgical experience and volume. Lack of endoscopic definition of a GJS, endoscopy of only symptomatic cases, and nonuniform postoperative gastric acid suppression also contribute to problems in the interpretation of postoperative results.

Conclusions

Footnotes

Disclosure Statement

No competing financial interests exist. All authors have contributed significantly to the drafting, reviewing, and final approval of this article.

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