title: Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost.
abstract: BACKGROUND
  The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure.
  
  
  METHODS
  We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD.
  
  
  RESULTS
  Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different.
  
  
  CONCLUSIONS
  The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.
authors.affiliation: Department of Surgery, Minimally Invasive Surgery, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA 30322, USA. fchavarriaga@hotmail.com
authors.forename: Luis Felipe
authors.initials: LF
authors.lastname: Chavarriaga
authors.forename: Michael W
authors.initials: MW
authors.lastname: Cook
authors.forename: Brent
authors.initials: B
authors.lastname: White
authors.forename: Louis
authors.initials: L
authors.lastname: Jeansonne
authors.forename: Nana
authors.initials: N
authors.lastname: Gletsu
authors.forename: Cheryl B
authors.initials: CB
authors.lastname: Parker
authors.forename: John
authors.initials: J
authors.lastname: Sweeney
authors.forename: S Scott
authors.initials: SS
authors.lastname: Davis
authors.forename: Edward
authors.initials: E
authors.lastname: Lin
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D003365:Costs and Cost Analysis; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D013270:Stomach / Q000601:surgery; D017792:Surgical Stapling / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult