title: The Effect of Route of Anvil Insertion on Stricture Rates with Circular Stapled Gastrojejunostomy During Laparoscopic Gastric Bypass.
abstract: BACKGROUND
  A higher incidence of gastrojejunal (GJ) anastomotic strictures has been reported following laparoscopic gastric bypass (LRYGB) with the 21 mm compared to 25 mm circular stapler. We hypothesized that the rate of stricture formation is affected by route of anvil insertion and its position relative to the gastric pouch staple line [trans-gastric above staple line (trans-gastric) vs. trans-oral through staple line (trans-oral)] following LRYGB.
  
  
  METHODS
  Retrospective review of consecutive patients who underwent LRYGB with circular stapled GJ studied in four groups: trans-gastric-21 mm, trans-gastric-25 mm, trans-oral-21 mm, and trans-oral-25 mm. Primary outcome studied was GJ stricture; secondary outcomes were results with endoscopic therapy and weight loss at 12 months. Predictors studied were age, gender, body mass index (BMI), comorbidities, and operative technical factors including anvil size and insertion route. Regression analyses were performed to identify predictors of GJ stricture.
  
  
  RESULTS
  Eight hundred seventy-six patients underwent LRYGB. Seventy-six (8.7 %) developed a GJ stricture. The highest stricture rate occurred in the trans-gastric-21 mm group (17 %, p < .01 for all comparisons). Stricture rates were similar for trans-gastric-25 mm (8.4 %), trans-oral-21 mm (5.2 %), and trans-oral-25 mm (1.6 %) groups. Independent predictors of stricture were: trans-gastric-21 mm (OR 10.9, 95%CI 1.4-85.1; p = .022) and age (OR 0.97, 95%CI 0.95-0.99; p = .002). Endoscopic dilation relieved symptoms in all patients. There was no difference in %EWL at 12 months in patients with and without a stricture.
  
  
  CONCLUSIONS
  We conclude that the trans-oral-21 mm anvil is associated with a low stricture rate. With the advantage of smaller abdominal wall wound, trans-oral-21 mm may be the preferred size and route of anvil insertion.
authors.affiliation: Section of Foregut and Bariatric Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
authors.forename: Jad
authors.initials: J
authors.lastname: Khoraki
authors.affiliation: Section of Foregut and Bariatric Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
authors.forename: Luke M
authors.initials: LM
authors.lastname: Funk
authors.affiliation: Section of Foregut and Bariatric Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
authors.forename: Jacob A
authors.initials: JA
authors.lastname: Greenberg
authors.affiliation: Section of Foregut and Bariatric Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
authors.forename: Glen
authors.initials: G
authors.lastname: Leverson
authors.affiliation: Section of Foregut and Bariatric Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. gcampos@vcu.edu.|Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, 1200 East Broad Street, PO Box 980519, Richmond, VA, 23298, USA. gcampos@vcu.edu.
authors.forename: Guilherme M
authors.initials: GM
authors.lastname: Campos
mesh_terms: D000328:Adult; D000367:Age Factors; D015992:Body Mass Index; D003251:Constriction, Pathologic / Q000209:etiology*; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies; D012737:Sex Factors; D017792:Surgical Stapling / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D016896:Treatment Outcome
keywords: Anastomosis; Anvil; Bariatric; Circular stapler; Gastric bypass; Gastrojejunostomy; Laparoscopic gastric bypass; Stricture