Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients

Lester Carrodeguas, Samuel Szomstein, Natan Zundel, Emanuel Lo Menzo, Raul Rosenthal
Surgery for Obesity and Related Diseases 2006, 2 (2): 92-7

BACKGROUND: The development of an anastomotic stricture at the site of the gastrojejunostomy following Roux-en-Y gastric bypass (RYGBP) is associated with substantial morbidity. Various techniques are available for creating the gastrojejunal anastomosis, including hand-sewing and using a circular or linear stapler, to reduce complication rates. The aim of this study was to assess the incidence of gastrojejunal anastomotic strictures in patients who underwent antecolic antegastric Roux-en-Y gastric bypass (AA-RYGBP) with the use of a linear stapler and to evaluate the outcomes of endoscopic pneumatic dilatation as a treatment option for patients with anastomotic stricture.

METHODS: All patients who met the National Institutes of Health (NIH) criteria for bariatric surgery and underwent AA-RYGBP using a linear stapler technique between July 2000 and November 2004 were included in the study. Following Institutional Review Board approval, the medical records of these patients were retrospectively reviewed. Two surgeons performed all of the surgical procedures in this series using a standardized surgical protocol.

RESULTS: Between July 2000 and November 2004, 1291 patients (1016 females [79%] and 275 male [11%]) underwent AA-RYGBP. The patients' mean age was 43 years (range, 19-75 years), and mean preoperative body mass index (BMI) was 49.6 kg/m2 (range, 34-97.5 kg/m2). Out of 1291 procedures, 1265 were performed laparoscopically (98.3%), with the reminder performed by laparotomy. A linear stapler was used to create the gastrojejunal anastomosis in all of the procedures. A total of 405 (31%) complications occurred, with gastrojejunal anastomotic strictures the most common complication, found in 94 (7.3%) patients more than 30 days after the procedure. All of these cases of stricture were treated by endoscopic pneumatic dilatation with a through the scope (TTS) balloon, requiring between one and four dilatory sessions. Of the 94 patients (2.1%) who underwent balloon dilatation, 2 developed perforation, only 1 of whom required surgical intervention. The mean postoperative hospital stay for the 94 patients was 4.2 days (range, 2-24 days); there was no perioperative patient mortality.

CONCLUSIONS: Our results demonstrate that AA-RYGBP can attain a relatively low complication rate and no mortality. Gastrojejunal anastomotic strictures were the most common complication and were diagnosed 30 days after the procedure. Endoscopic balloon dilatation can be offered as a first-line treatment for gastrojejunal anastomotic strictures. Perforation is a potential complication of this treatment and may necessitate surgical intervention.

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