title: Intraoperative endoscopic pneumatic testing for gastrojejunal anastomotic integrity during laparoscopic Roux-en-Y gastric bypass.
abstract: BACKGROUND
  Gastrojejunal anastomotic leaks remain a major source of morbidity following laparoscopic gastric bypass. Intraoperative pneumatic testing has been offered as a method to reduce the incidence of this complication. This study's purpose was to assess the efficacy of intraoperative pneumatic testing during laparoscopic gastric bypass, to evaluate the types of air leaks detected, and to develop an algorithm for management that takes into account air leak categorization and drainage.
  
  
  METHODS
  A retrospective analysis was performed on the initial 257 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 36-month period. The gastrojejunostomy was constructed using a linear stapler technique. All patients underwent intraoperative endoscopic pneumatic testing with a clamp applied to the Roux limb. All patients underwent water-soluble upper gastrointestinal radiography on the first postoperative day.
  
  
  RESULTS
  Patients were divided based on the pneumatic testing results into groups for data analysis: persistent air leak (group 1), non-reproducible air leak (group 2), and no air leak (group 3). The overall age (41.7+/-9.3 years), body mass index (BMI) (47.3+/-6.4 kg/m2), conversion rate (2%), and length of stay (1.9+/-2.0 days) were not statistically different among groups (p>0.05). In group 1, the air leak site was repaired, and 11 (92%) were drained. In group 2, the air leak site could not be identified, and all 12 (4.7%) were treated by drainage alone. In group 3, drains were placed in 12 (5.2%) due to difficult construction of the gastrojejunostomy. Overall postoperative gastrointestinal leak rate was 0.78%. No postoperative clinical or radiological gastrointestinal leaks occurred within the region tested pneumatically. Intraoperative complications related to pneumatic testing occurred in 1 (0.39%) patient.
  
  
  CONCLUSIONS
  Intraoperative pneumatic testing of the gastrojejunal anastomosis is a safe and rapid means of evaluating anastomotic integrity. Application of this technique permitted timely repair of flawed anastomoses, thereby averting potential postoperative leaks.
authors.affiliation: Department of Bariatric Surgery, University of Maryland, 22S. Greene Street, N4E27, Baltimore, MD 21201, USA. mkligman@smail.umaryland.edu
authors.forename: M D
authors.initials: MD
authors.lastname: Kligman
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y; D004724:Endoscopy; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D007327:Insufflation / Q000379:methods; D007431:Intraoperative Complications / Q000175:diagnosis*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged