title: A zero leak rate in 251 consecutive laparoscopic gastric bypass operations using a two-layer gastrojejunostomy technique.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institute, Baltimore, Maryland 21224, USA. mschwei7@jhmi.edu
authors.forename: Michael A
authors.initials: MA
authors.lastname: Schweitzer
authors.forename: Anne
authors.initials: A
authors.lastname: Lidor
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Magnuson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000713:Anastomosis, Roux-en-Y; D005260:Female; D015390:Gastric Bypass / Q000379:methods*; D006801:Humans; D007582:Jejunostomy / Q000379:methods; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome