Gastric Bypass: Transoral Circular-Stapled Gastrojejunostomy Technique

Fig. 1.

Operating room setup for gastric bypass. Copyright CCF.

Fig. 2.

Port placement for circular-stapled gastrojejunostomy technique. Copyright CCF.

Pouch Reconstruction

The patient is placed in extreme reverse Trendelenburg position and attention is turned to the hiatus. We start the procedure by dissecting off the phrenoesophageal fat to expose the left pillar of the diaphragm using hook electrocautery. With the help of the pneumoperitoneum, dissection continues laterally closer to the greater curvature until the first branch of short gastric vessel is reached. This limited dissection facilitates pouch construction by mobilizing the most cephaled part of the lateral pouch. We then open the pars flaccida and perform a blunt dissection to expose the posterior gastric wall. A 3.5-mm cartridge load of 60-mm linear stapling device with staple-line buttress material is used to take the descending branch of the left gastric vessels. The buttress allows for easy maneuverability of the pouch without actually grasping tissue. A single load of 60-mm (3.5-mm cartridge) stapler in a horizontal orientation, and 2–3 vertical applications typically complete the pouch. It is important when firing the vertical loads to avoid crossing the previous staple line and to ensure that the stapler is lateral to the angle of His when firing the final load. This approximately 30 cm³ vertically oriented pouch will be sufficient in size to admit the anvil of the 21-mm circular stapler. The staple line is inspected for quality of staple application and for any bleeding. Hemostasis is important as hematoma formation on the staple line could cause staple-line dehiscence and gastric pouch leak.

The Roux and Biliopancreatic Limb Constructions

Once the pouch is completed, we construct the Roux and biliopancreatic limbs. The patient is placed in a supine position. The omentum and transverse colon are gently swept cephalad to identify the ligament of Treitz. The duodenum is identified and confirmed by the adjacent IMV. We then measure 40–50 cm from the ligament of Treitz and divide the small bowel using a linear cutter stapler with 2.5-mm cartridge load. To achieve more mobility of the Roux limb, the small-bowel mesentery is further divided with ultrasonic shears with care taken to avoid devascularizing the biliopancreatic limb or to approach too close to the root of the mesentery. A 150-cm Roux limb is then measured out and a side-to-side jejunojejunostomy is fashioned between the biliopancreatic limb and the common channel. After stay sutures are placed, a single firing of a white 60-mm linear stapler makes the anastomosis and the common enterostomy is closed with hand-sewn running absorbable suture. The mesenteric defect is closed with a hand-sewn running, locking permanent suture. The omentum is then split with ultrasonic shears in preparation for transmission of the Roux limb in an antecolic position.

Gastrojejunostomy Anastomosis

For transoral placement of the anvil, we use the Orvil package (Covidien, Mansfield, MA), which consists of a 21-mm anvil with the head pre-tilted and the tip attached to an oral gastric tube. The tube is passed similar to an orogastric tube downward until it protrudes against the pouch. Gentle manipulation is used to direct the tip of the tube to the chosen place for the gastrotomy. During the oral passage, it is important to ensure that the anvil does not get caught on the teeth or the endotracheal tube at the narrowest area of the anvil’s transit, which is at the level of the balloon. Application of a jaw thrust and control of the endotracheal tube are important when introducing the anvil.

Once advanced, hook electrocautery is used to make a small gastrotomy against the tip of the tube that is pushed gently downward (Fig. 3). The oral gastric tube is advanced through the gastrotomy and it is pulled out through the trocar while applying a gentle counter-traction on the pouch (Fig. 4). We prefer to make our gastrotomy immediately posterior to the horizontal staple line. The stitch that has kept the anvil head in a tilted position is cut, and the tube is detached from the anvil and passed off the surgical field.

Fig. 3.

Hook cautery is used to make a small gastrotomy posterior to the horizontal staple line on the pouch. The tube can be gently advanced against the gastric wall to position the opening correctly. Copyright CCF.

Fig. 4.

The orogastric tube is pulled through a laparoscopic port to deliver the anvil into the pouch. Copyright CCF.

In preparation for the placement of the 21-mm circular stapler, a retractable sterile sleeve is fashioned around the tip of the circular stapler to minimize the skin wound contamination upon removal. The 15-mm port site at the left upper quadrant is dilated then the circular stapler is inserted directly through the skin. The Roux limb is then brought up to gastric pouch without any undue tension and traced back to the jejunojejunostomy to check for any twist. The Roux limb staple line is excised and the circular stapler is introduced into the lumen of the Roux limb through the enterotomy and advanced several centimeters inside the lumen. The spike of the stapler is then advanced to penetrate the Roux limb wall on the antimesenteric side. The stem of the anvil is then grasped by the surgeon and united to the spike. The circular stapler is closed slowly while the assistant maintains the orientation of the Roux limb during stapler closure. Once it is fired, the stapler is opened and rotated as it is withdrawn from the formed anastomosis. The previously placed sterile sleeve is then retracted over the tip, covering the contaminated end. The stapler is withdrawn from the abdomen and the 15-mm port is reinserted. The enterotomy is closed with an application of the linear stapling device leaving a very short candy cane. A medial and a lateral absorbable suture are placed at each side of the anastomosis and the tails are left intentionally long. In addition to help to minimize any tension on the anastomosis, these sutures can be used to rotate and bring the posterior staple line anteriorly for inspection in case of a bleeding or a leak. The anterior anastomosis line is hand oversewn with additional interrupted sutures.

Endoscopy and Leak Test

The Roux limb is then occluded, the abdomen is filled with saline, and diagnostic upper endoscopy is performed. Pouch configuration and size are examined. The gastrojejunostomy is evaluated for patency, bleeding, and disruption. Gentle insufflation also allows for laparoscopic detection of leak by examining for any bubbles. We routinely leave a channel drain at the gastrojejunostomy.

Outcomes

The overall 30-day mortality for bariatric surgical procedures is less than 1 % [7].

Among both early and late complications, anastomotic leaks remain one of the most challenging complications. The rate of anastomotic leak in RYBG is 1.5–6 % and can be as high as 35 % in revisional surgery [8].

Carrasquilla et al. have reported a low incidence of leaks at 0.1 %. Their technique involves the antecolic and antegastric approach and the use of a circular stapler for the gastroenterostomy [9].

Most leaks occur early in the first week after surgery but can occur up to a few weeks later. If not diagnosed in a timely fashion, the mortality rate increases dramatically. Early clinical symptoms of a leak are subtle and require clinical vigilance for signs such as low-grade fevers, sustained tachycardia, or respiratory distress. If a leak is suspected clinically, emergent surgical exploration should be performed even if imaging is negative, given the rapid progression to sepsis in the severely obese patient.

The surgical principles in treating a leak include providing broad-spectrum antibiotic coverage, identification and repair of the defect, irrigation and control of contamination, wide drainage of the contaminated area and providing enteral access for feeding. Percutaneous drainage of a contained fluid collection may be an option in patients who are stable [10].

Giordano et al. performed a meta-analysis comparing linear versus circular stapler technique with a primary outcome of gastrojejunal anastomosis leak. Eight studies involving 1,321 patients were retrieved and included in this study. All eight studies reported results on gastrojejunostomy leakage, and pooled analysis did not show significant difference between the two groups (RR, 1.03; 95 % CI, 0.36–2.93; p 0.95) [11].

Bleeding

Significant bleeding after gastric bypass was observed more following laparoscopic versus open GBP. The overall rate is 0.6–4 % [12].

Early bleeding typically occurs from one of the anastomotic or staple lines. It is most commonly intraluminal. Tachycardia, a decreased hematocrit, and melena are the most common presentations. Intraluminal bleeding typically resolves without surgical intervention, but may require transfusion of blood products. For ongoing bleeding with high transfusion requirements, endoscopic intervention is appropriate. Laparoscopic exploration and oversewing of the staple line, occasionally with concomitant endoscopy, is the definitive treatment in patients who fail endoscopic management or for intraluminal bleeding not amenable to endoscopic therapy.

Nguyen et al. reported that 3.2 % of patients who underwent a LRYGB with creation of the gastrojejunostomy anastomosis with a circular stapler developed postoperative hemorrhage in 24 h after surgery. Recent meta-analysis comparing linear versus circular stapler technique to evaluate this issue showed no significant differences between the groups in the incidence of stomal ulcer or postoperative bleeding [11].

Wound Infection

Some authors have reported an increased frequency of wound infection with circular stapler, related to the extraction of the contaminated handpiece through a port [13].

The rate of infection at the abdominal wall site could be reduced down to 1 % by protecting the wound with a plastic sheet and this is our preferred technique [14].

Gastrojejunal Strictures

Among the most significant postoperative complications are gastrojejunal (GJ) anastomotic strictures. There is considerable variability in stricture rates between different surgical techniques with an incidence of 1–31 % in some series [13, 15].

Overall, the gastrojejunal stenosis rate is higher in laparoscopic gastric bypass compared with open technique [12].

Creation of the GJ anastomosis can be accomplished via a hand-sewn technique or utilization of a linear or circular stapler (either 21 or 25 mm in diameter).

A 2008 online survey of American Society for Metabolic and Bariatric Surgery revealed that the circular stapler technique is the most commonly used technique by bariatric surgeons to construct the gastrojejunostomy. Furthermore, an increasing number of surgeons use this technique compared with a prior survey [16].

In an Internet-based survey, Madan et al. reported on the preferred surgical technique for GJ: 43 % of the surgeons performed a circular-stapled technique, while 41 % prefer linear stapling, and 21 % prefer the totally hand sewn.

Selection of a particular technique to create the gastrojejunal anastomosis is based on a range of factors. The 21-mm circular-stapled anastomosis has been our preference. It gives a uniformly reproducible 12-mm diameter stoma that delays gastric pouch emptying. The success of the gastric bypass as a weight loss procedure depends somewhat on its restrictive component that results from creation of a small pouch to restrict food intake combined with a narrow outlet to limit pouch emptying and hence, inducing the feeling of the satiety. This involves the appearance of stenosis with an incidence ranging from 3 to 27 % [17].

Even within anastomotic technique categories, there is significant variability in stricture rates. This variation in rates may be partly explained by how the stricture is defined or diagnosed among the surgeons and the endoscopists [14, 18].

The etiology of stricture formation is uncertain, although tissue ischemia, excessive scarring from undetected leakage, gastric acid hypersecretion, and increased tension on the gastrojejunal anastomosis are believed to have major roles. Gastroesophageal reflux disease and age have been shown to be statistically significant independent predictors of stricture [19].

With circular staplers, several studies have published higher rates of GJ strictures, with the highest rates specifically with the 21-mm circular staplers. However, we believe that the most important factor that influences potential stricture development is surgeon experience and technique.

Carter et al. describe a series of 654 consecutive RYGB performed open or laparoscopically. Univariate analysis revealed that surgeon experience was a risk factor for stricture formation for the first 50 gastric bypasses [20].

Perugini et al. reported a decrease in the rate of anastomotic stricture from 17 to 4 % from their first 100 patients compared with their second 100 patients with the same anastomotic technique [21].

Suter and his group were able to reduce their stricture rates to 0.8 % after introducing a slight modification of their surgical technique by encompassing the pouch horizontal staple line in the circular staple line [18].

Whether the higher stricture rate with circular staplers reflects procedures performed on the steep portion of the laparoscopic gastric bypass learning curves is another consideration. Investigators from McGill looked at a series of 201 consecutive LRYGB performed by a single surgeon. They noticed that the anastomotic stricture rates decreased from 11.9 % in the first 67 patients to 3.0 % in the remaining patients (p 0.01) [21].

Since 1993 and throughout their program’s history, Wittgrove and his group have maintained a rate around 3.8 % utilizing the 21-mm circular stapler [23].

This rate of stricture is among the lowest seen with the 21-mm circular stapler and is comparable to the lowest rates of all techniques reported in the recent literature. With early dilation of 12–15 mm proving to be an effective and safe treatment for strictures, most patients have resolution of symptoms after only one therapeutic endoscopy [24–26].

Nontechnical factors have also been implicated in postoperative stricture formation. Takata et al. propose that ischemia, excessive scar formation, and gastric hypersecretion can all promote stricture formation. Importantly, smoking and NSAID use are considered modifiable risk factors for gastrointestinal strictures.

Several other factors may lead to a higher stricture rate, including demographic attributes, comorbid disease, and the use of nonabsorbable Lembert sutures to reinforce the gastrojejunostomy [27].

Patients typically present several weeks after surgery with nausea, vomiting, dysphagia, gastroesophageal reflux, and eventually an inability to tolerate oral intake.

The majority of strictures occur within the first 4–6 weeks after surgery, and some strictures occur later and are generally related to smoking or medication usage [28].

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