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.
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).
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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Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353–7.
Leyba JL, Llopis SN, Isaac J, Aulestia SN, Bravo C, Obregon F. Laparoscopic gastric bypass for morbid obesity—a randomized controlled trial comparing two gastrojejunal anastomosis techniques
Jiang H-P, Lin L-L, Jiang X, et al. Meta-analysis of hand-sewn versus mechanical gastrojejunal anastomosis during laparoscopic Roux-en-Y gastric bypass for morbid obesity. Int J Surg. 2016;32:150–7.
Kimura M, Takahashi H, Tanaka T, et al. Profiling surgical staplers: does staple direction affect the strength of the anastomosis? Dig Surg. 2015;32:454–8.
Bendewald FP, Choi JN, Blythe LS, et al. Comparison of hand-sewn, linear-stapled, and circular-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2011;21:1671–5.
Korenkov M, Goh P, Yücel N, et al. Laparoscopic gastric bypass for morbid obesity with linear gastroenterostomy. Obes Surg. 2003;13(3):360–3.
Gould JC, Garren M, Boll V, et al. The impact of circular stapler diameter on the incidence of gastrojejunostomy stenosis and weight loss following laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2006;20:1017–20.
Varban OA, Cassidy RB, Sheetz KH, et al. Technique or technology? Evaluating leaks after gastric bypass. Surg Obes Relat Dis. 2016;12:264–72.
Kim J, Azagury D, Eisenberg D, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11:739–48.
Csendes A, Burgos AM, Braghetto I. Classification and management of leaks after gastric bypass for patients with morbid obesity: a prospective study of 60 patients. Obes Surg. 2012;22:855–62.
Liu B, Liu Y, Liu J, et al. Comparison of hand-sewn and stapled anastomoses in surgeries of gastrointestinal tumors based on clinical practice of China. World J Surg Oncol. 2014;12:292.
Farrah JP, Lauer CW, Bray MS, et al. Stapled versus hand-sewn anastomoses in emergency general surgery. J Trauma Acute Care Surg. 2013;74:1187–94.
Hemming K, Pinkney T, Futaba K, et al. Systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures Lin SJ (ed.). PLoS One. 2013;8:e75132.
Lönroth H, Dalenbäck J, Haglind E, et al. Laparoscopic gastric bypass. Surg Endosc. 1996;10:636–8.
Szomstein S, Whipple OC, Zundel N, et al. Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis. Surg Obes Relat Dis. 2006;2:431–4.
Hasegawa S, Nakayama S, Hida K, Kawada K, Sakai Y. Effect of Tri-Staple™ technology and slow firing on secure stapling using an endoscopic linear stapler. Dig Surg 2015;32:353–360.
Himpens JM. The gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Semin Laparosc Surg. 2004;11:171–7.
Cardoso R. (2018). The technique to perform a safe and effective gastrojejunostomy in RYGB. [WWW document]. URL https://www.websurg.com/search/?search_q=cardoso+ramos#search_q=cardoso+ramos&viewMode=dataList&keywords=&sort_field=publication_date&sort_order=-1
Higa G, Abdemur A, Szomstein S, Rosenthal R. (2018). Laparoscopic Lysis Of Adhesions And Redo Of Gastrojejunostomy After Gastric Bypass - YouTube. [WWW document]. URL https://www.youtube.com/watch?v=s-Wkg-blWDA
Gagne D. (2018). SAGES Top 21 Videos: Laparoscopic Roux-en-Y gastric bypass - YouTube. [WWW document]. URL https://www.youtube.com/watch?v=ohF1sDwmWiQ
Vix M, D’Urso A, Marescaux J. (2018). Laparoscopic Roux-en-Y gastric bypass with linear gastrojejunostomy. [WWW document]. URL https://www.websurg.com/search/?search_q=gastrojejunostomy%2C+RYGB#search_q=gastrojejunostomy%2C+RYGB&viewMode=dataList&keywords=
Tozzi P, Corno A, Hayoz D. Definition of arterial compliance. Re: Hardt et al, "Aortic pressure-diameter relationship assessed by intravascular ultrasound: experimental validation in dogs" Am J Physiol Heart Circ Physiol 2000;278:H1407.
Toro JP, Patel AD, Lytle NW, et al. Observed variability in sleeve gastrectomy volume and compliance does not correlate to postoperative outcomes. Surg Laparosc Endosc Percutan Tech. 2015;25:324–30.
M.S., A.K. and K.C. were responsible for specimen preparation and processing, data collection and processing. All authors participated in data analysis and manuscript writing. C.L. was responsible of data processing on MatLab®. A.A.T., C.L. and R.S. were responsible for statistical analysis of the results.
A.A.T. is a clinician scientist supported by the National Institute for Health Research (NIHR) in the UK. The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the NIHR or the Department of Health.
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical Approval Statement
All procedures involving animal tissues were in accordance with Heart of England NHS Foundation Trust policy for the use of animal tissues for training/research purposes in accordance with the National Centre for the Replacement Refinement and Reduction of Animals in Research guidelines.
All porcine tissues used in the study were collected and processed in accordance with The Animal By-products Regulations 2005 (Regulation EC no. 142/2011).
All applicable institutional and/or national guidelines for the care and use of animals/animal tissues were followed.
Informed Consent Statements
Does not apply.
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Sahloul, M., Karim, A., Chohan, K.S. et al. Roux-en-Y Gastric Bypass: Does the Direction of Staples Matter?. OBES SURG 28, 2868–2873 (2018). https://doi.org/10.1007/s11695-018-3275-z
- Bariatric surgery
- Burst pressure
- Stapled anastomosis
- Staple direction
- Linear stapler