PURPOSE: Laparoscopic
Roux-en-Y gastric bypass is quickly replacing open techniques in the
morbidly obese patient who presents for
surgical treatment. Safety concerns about the laparoscopic technique have arisen in the literature with gastrojejunostomy
leak rates of 5% or greater reported in several series. MATERIALS AND METHODS: A total of 251 consecutive
gastric bypass operations were performed from August 2001 to January 2004 by a single surgeon with over 6 years' experience. A double layer technique was used for every gastrojejunostomy
anastomosis. This consisted of end-to-side stapled
anastomosis using only 30 mm of a 45 mm blue (3.5 mm) staple cartridge that was fired inside the
gastric pouch and Roux limb. A
posterior running suture was then used to reinforce the back wall. An
intraluminal 32F bougie was placed before the stapler opening was closed. Finally, 2 running sutures were used to reinforce the
anterior and lateral sides of the
anastomosis. RESULTS: The
average patient age was 43 years (range, 18-67 years), 89% were female,
average preoperative weight was 137 kg (range, 89.5-214.5 kg), and
average body mass index of 49 kg/m2 (range, 35-75). One hundred forty-two cases were performed with the Ethicon
endoscopic linear stapler and 109 with the United States
Surgical endoscopic linear stapler. There were no
anastomotic leaks, staple line
leaks,
pulmonary emboli, or in-hospital deaths recorded.
Endoscopic dilation successfully treated 10 (4%) cases of stomal
stenosis. Eleven (4%) patients developed
marginal ulcers that were easily treated with a
proton pump inhibitor.
Average excess
weight loss at 12 months and 18 months was 63% and 71%, respectively. CONCLUSIONS: Laparoscopic results are as good as or better than open
surgery in the
morbidly obese patient. The learning curve for this operation is steep and this may be reflected in the higher
leak rates reported in earlier series. However, the technique used to create the gastrojejunostomy
anastomosis may also account for a lower
leak rate. The two-layer gastrojejunostomy
anastomotic technique combines an inner stapled layer and outer sutured layer that yields excellent results.
