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Gastrojejunal Anastomosis in LRYGB – Hand-sewn vs Circular vs Linear
Posted in Lectures on 28 May 2019

Sara Tavares Nogueira, MD
General Surgery Specialist
Hospital Clínic Barcelona

INTRODUCTION

Obesity is defined as an excess of body fat relative to lean body mass. Clinically, it is measured through the body mass index (BMI), calculated by dividing the weight by twice the height.
It is an epidemic, affecting 39% of the adult population worldwide, according to the World Health Organization’s latest data.
There a variety of metabolic changes, comorbidities and diseases associated with obesity overweight, such as hypertension, type 2 diabetes and sleep apnea, wchi are intertwined and lead to chronic disability and higher mortality risk.
Treatment of obese patients requires a multidisciplinary team of Endocrinologists, Nutritionists, Psychologists/Psychiatrists and Bariatric Surgeons, to better define the strategy.
Bariatric surgery has been proved to be the best way to achieve persistent weight loss and resolution of obesity-related comorbidities.
It is indicated when the patient presents with a BMI equal or over 40, or 35 if there are associated comorbidities. In certain patients with uncontrolled type II diabetes and metabolic syndrome, a cutoff BMI of 30 Kg/m2 may be used.

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS

Laparoscopic Roux-en-Y bypass was first performed in 1994 and it has become the gold standard procedure against which every other bariatric procedure is measured.
It is associated with low morbidity and mortality and is a restrictive and malabsorptive procedure, reducing the food intake and the amount of nutrients absorbed.
It also works by inducing physiological and hormonal responses.
The procedure involves the creation of a gastric pouch, a gastrojejunal anastomosis between the pouch and the alimentary limb and a jejunojejunostomy between the alimentary limb and the biliary limb.
The gastrojejunal anastomosis can be created in 3 different ways: hand-sewn, stapled circular, or stapled linear.

HAND-SEWN GASTROJEJUNAL ANASTOMOSIS

It consists in the creation of a side-to-end anastomosis. It has the advantages of allowing for direct examination of the anastomosis, reducing the rate of anastomotic bleeding, adjustment of the suture according with tissue thickness, completion of the anastomosis if the stapling device fails, and it does not require the size of the trocars to be increased.
It can also be adapted to difficult anatomic situations that preclude the use of a stapler.
The most important disadvantage is that it requires high laparoscopic suturing skills.

STAPLED CIRCULAR GASTROJEJUNAL ANASTOMOSIS

The stapled circular gastrojejunostomy is an end-to-end anastomosis between the stomach and the Roux limb.
It can be done through 2 routes: trans-oral or trans-abdominal.
This technique offers some advantages: is easier to perform as it does not require sewing; orograstric placement requires fewer laparoscopic skills, but is associated with an increased risk of esophageal trauma and infection; the anastomosis is calibrated with the stapler and is uniform.
On the other hand, this technique requires enlargement of one of the ports, has a higher incidence of anastomotic stenosis (specially with 21 mm devices), and requires an experienced assistant.

STAPLED LINEAR GASTROJEJUNAL ANASTOMOSIS

The stapled linear technique creates a side-to-side linear anastomosis between the gastric pouch and the jejunal limb.
The main advantages of the stapled linear variation is that it does not need an experienced assistant nor port enlargement.
Disadvantages include operator-dependent variations in anastomotic size, and increased difficulty when compared to its stapled counterpart.

HAND-SEWN VS STAPLED CIRCULAR VS STAPLED LINEAR GJ

There is no data from randomized controlled trials comparing the 3 types of procedures, only retrospective studies and meta-analyses.
No differences were found regarding leak rate, length of surgery or the amount of weight lost.
The choice of procedure is guided mainly by the surgeon, their training and expertise, and their preferences.
Nevertheless, an expert bariatric surgeon must master all the techniques and be ready to change options if necessary.