Next, the pouch is fashioned using several firings of a laparoscopic gastrointestinal anastomosis (GIA) stapler. We currently use the articulating Endo GIA Ultra Universal Stapler with the 3.5-mm purple tri-staples (Covidien, Mansfield, MA) (Fig. 3). As with any stapled gastrojejunostomy, care must be taken to ensure that no tubes, such as nasogastric tubes or temperature probes, remain within the stomach before creating the pouch, as they are at risk for division by the GIA stapler. Such an oversight may result in staple-line disruption, leak, and retained tube fragment.

The gastrotomy is approximated with three tacking sutures and closed with an application of the Endo GIA Universal Straight Stapler with the blue 3.5-mm load (Covidien, Mansfield, MA). Finally, the EEA is placed through a port site and once within the Roux limb it is mated with the anvil (Fig. 4). We use a 25-mm anvil with the Tilt-Top feature that increases the ease of removal (Premium Plus CEEA Stapler, Covidien, Mansfield, MA). Before deploying the EEA, the mesentery of the Roux limb should be inspected to ensure that it is oriented properly. The EEA is fired and removed.

The open end of the Roux limb is then excised again using the Endo GIA Universal Stapler but with the shorter, 2.5-mm white staples (Fig. 5). The anastomosis is reinforced with several absorbable horizontal mattress sutures in order to decrease tension. The gastrojejunostomy is then tested for leaks by injecting methylene blue via a nasogastric tube. Alternatively, endoscopic insufflation may be performed, evaluating the anastomosis by air leak test. On postoperative day 1, we routinely order an upper gastrointestinal (UGI) contrast study to evaluate for leaks, although recent data suggests that this practice may not be cost effective [11, 12].

Success with either the transgastric or transoral technique should be expected to be comparable as they result in a technically similar gastroenteric anastomosis. Series data suggest that outcomes following circular stapled gastroenteric anastomosis are similar to those after hand-sewn or linear stapled anastomosis. Using the EEA, anastomotic leak rates following gastric bypass have ranged from 1.3 to 2.2 % [3, 13]. The leak rates among studies employing hand-sewn and linear stapled gastroenteric anastomoses have been similar (2–5.1 %) [14–16].

Anastomotic strictures may result from local ischemia, undue tension, or a technically narrow anastomosis. Such strictures may be managed safely with either pneumatic balloon or bougie dilation, thus averting the need for further surgical intervention [17]. Although some reports suggest a higher incidence of gastrojejunal stricture following circular stapled anastomosis, larger series have demonstrated acceptable rates of stenosis overall (1.6–6.9 %) [3, 18]. The data also shows that the increased risk is largely due to the use of smaller diameter anvils, which have no weight loss advantage over a larger anvil [19]. In patients where a 21-mm anvil was used, the stricture rate ranged from 9 to 26 %, while the 25-mm anvil stricture rate was 2.9–10 % [20–22]. In one study of 200 patients where 21-mm anvils were compared to 25-mm anvils, patients with smaller anvil diameters had an increased rate of symptoms leading to endoscopy and presented with these symptoms significantly earlier [23]. Based on the above data, the 25-mm anvil is recommended. In our experience, the stricture rate from June 2011 through June 2012 was 8.57 % [24]. All of the patients presented within the first 60 postoperative days and responded well to endoscopic dilation. To date, we have never revised the anastomosis as the result of a stricture.

Some surgeons who use the circular stapler have reported success with biological staple reinforcements. The data is limited; however, in a study of 596 patients whose anastomosis was created with a reinforced 25-mm anvil EEA, the strictures requiring intervention were 0.67 % in the reinforced group as compared to 9.41 % in the non-reinforced group [25]. Long-term data is needed before this can be routinely recommended.

All surgeons that use the various industry EEA devices may not universally apply transoral anvil placement. The transgastric approach allows for direct placement of a large diameter anvil at the intended anastomotic site without endangering the esophagus or requiring endoscopy [26] (Video Error! Reference source not found.).