title: Linear-stapled gastrojejunostomy with transverse hand-sewn enterotomy closure significantly reduces strictures for laparoscopic Roux-en-Y gastric bypass.
abstract: BACKGROUND
  Gastrojejunostomy (GJ) stricture is a common complication after Roux-en-Y gastric bypass (RYGB) for morbid obesity, and the optimal anastomotic technique remains uncertain. The objective of this study was to use cumulative summation (CUSUM) analysis to compare rates of gastrojejunostomy strictures after linear stapling with longitudinal versus transverse enterotomy closure in gastric bypass patients.
  
  
  METHODS
  Charts of all consecutive patients with at least 60 days of post-operative follow-up after laparoscopic RYGB (LRYGB) at our tertiary care institution from Nov 2009 to Dec, 2011 were retrospectively reviewed. Gastrojejunostomy stricture was diagnosed by history and upper endoscopy. CUSUM method of quality control analysis was used to determine sequential improvement in stricture rates with the change in technique.
  
  
  RESULTS
  A total of 197 patients were included (97 longitudinal closure, median age 44 (21-67), median BMI 47 (35-80), 85.8 % female). Gastrojejunostomy strictures occurred in 16 % of longitudinal and 0 % of transverse patients (p = <0.0001). CUSUM analysis demonstrated sequential statistically significant improvement in stricture rates after the change in technique was applied. The longitudinal group had a statistically significant increased rate of surgery-related readmissions (15.5 vs 6.0 %, p = 0.038), with 43.7 % of those readmissions related to GJ strictures. There were no other significant outcome differences between groups.
  
  
  CONCLUSIONS
  Linear-stapled anastomosis with a transverse enterotomy closure significantly reduces the rate of gastrojejunostomy stricture for LRYGB, considerably reducing procedural morbidity.
authors.affiliation: Division of General Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada M8Y 1E8.
authors.forename: Carmen L
authors.initials: CL
authors.lastname: Mueller
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Jackson
authors.forename: Todd
authors.initials: T
authors.lastname: Swanson
authors.forename: Kristen
authors.initials: K
authors.lastname: Pitzul
authors.forename: Chris
authors.initials: C
authors.lastname: Daigle
authors.forename: Todd
authors.initials: T
authors.lastname: Penner
authors.forename: David R
authors.initials: DR
authors.lastname: Urbach
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
mesh_terms: D000328:Adult; D000368:Aged; D002170:Canada / Q000453:epidemiology; D003251:Constriction, Pathologic / Q000453:epidemiology / Q000517:prevention & control; D004766:Enterostomy; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D007579:Jejunal Diseases / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009767:Obesity, Morbid / Q000150:complications / Q000453:epidemiology / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D017792:Surgical Stapling; D013536:Suture Techniques; D016896:Treatment Outcome