3.5mm circular stapler reduces complications vs 4.8mm

Using a 3.5mm circular stapler height compared to a 4.8mm stapler height to fashion the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) may reduce the rate of significant anastomotic bleeding and stricture formation, according to researchers from the University of Calgary, Calgary, the University of Alberta and the Royal Alexandra Hospital, Edmonton, Canada. The paper, ‘A Shorter Circular Stapler Height at the Gastrojejunostomy during a Roux-En-Y Gastric Bypass Results in Less Strictures and Bleeding Complications’, published in the Journal of Obesity, added that a randomised prospective trial may be best suited to add further information regarding the optimal circular stapler height for fashioning the GJ.

One of the most common complications of LRYGB occurs at the GJ staple line and although the circular stapler technique is routinely used to create the GJ anastomosis, the optimal circular stapler height to use remains controversial. Subsequently, the researchers performed a retrospective cohort study within the Alberta Provincial Bariatric Program (APBP) to compare outcomes between the 3.5mm and 4.8mm stapler heights. Patients underwent a LRYGB at two Canadian centres with the standardised surgical technique between the years 2015 and 2017. Surgeons at one centre were trained with those from the other centre thereby adding to the uniformity of surgical technique between sites.

The authors noted that the jejunojejunostomy is created in a side-to-side manner using an Echelon 60mm stapler (Ethicon). The biliopancreatic limb is measured to 50cm, while the Roux limb is approximated at 100cm. A gastric pouch is created along the lesser curve of the stomach using the Echelon 60mm stapler and a 50French bougie as a guide. The gastrojejunostomy is then fashioned by introducing an EEA 25mm stapler (3.5mm stapler height at site no. 1 vs 4.8 mm stapler height at site no.2 (Medtronic)) through an enlarged lateral port site. The Orvil device is passed transorally and an intraoperative upper endoscopy and a leak test with insufflation across the anastomosis are performed at the surgeon’s discretion.

In total, 215 patients who had a LRYGB done between the years 2015 and 2017 were identified - 143 patients had the GJ constructed with a 3.5mm circular stapler height, with the remaining 72 patients having the GJ fashioned with a 4.8mm stapler height. The follow-up time for this study was six months and no patients were lost to follow-up.

The researchers collected data on preoperative factors including age, gender, BMI, obesity-associated comorbidities (hypertension, dyslipidaemia, diabetes mellitus, and obstructive sleep apnoea), smoking status, preoperative anticoagulation use and preoperative haemoglobin levels. They also recorded peri- and post-operative complication events within six months after surgery including haemorrhage (defined as the need for a blood transfusion prior to discharge), anastomotic stenosis requiring balloon dilation with endoscopy, marginal ulcer formation identified on upper endoscopy, anastomotic leaks, all cause reoperation and return emergency room visits, intensive care unit admission rate and mortality.

Outcomes

They reported no difference in preoperative age, BMI, obesity-related comorbidities, preoperative haemoglobin or significant intraoperative complications between the two groups. However, postoperative bleeding (requiring a blood transfusion) was significantly lower in the 3.5mm stapler height group compared to the 4.8mm stapler height group (6.3% versus 15.3%, p=0.04). There was no difference in the transfusion threshold (haemoglobin of 91 versus 88 g/L, p=0.062) or the number of units of blood delivered (2.1 versus 2.9, p=0.024) between the groups. The source of bleeding was primarily intraluminal in the 4.8mm group.

The occurrence of GJ anastomotic strictures requiring balloon dilation was significantly less in the 3.5mm stapler height group vs the 4.8 mm group (3.5% versus 13.9%, p=0.008) and there was no difference in the average time to first dilation (61.4 days versus 55.8 days, p=0.79) or the total number of dilations required (2.4 versus 2.3, p=0.94).

In addition, they also reported no significant difference in the rate of marginal ulcer formation (4.9% versus 4.2%, p=0.99), no difference in the rate of anastomotic leaks (0.7% versus 0.0%, p=0.99), intensive care unit admissions (0.0% versus 2.8%, p=0.11), or rate of reoperation (6.0% versus 9.7%, p=0.41) between the stapler height groups and there were no mortalities. The 3.5mm stapler group had a significantly shorter length of stay in hospital compared to the 4.8 m stapler group (2.5 days versus 3.1 days, p=0.0001).

“Our results suggest that use of a 3.5 mm circular stapler height compared to a 4.8 mm stapler height to fashion the GJ during LRYGB may reduce the rate of significant anastomotic bleeding and stricture formation,” the authors conclude. “A randomised prospective trial may be best suited to add further information regarding the optimal circular stapler height for fashioning the GJ.”