the gastric bypass in its various forms has been performed since 1967 . in 1991 , the national institutes of health issued a consensus statement advocating surgery as the most consistent and effective therapy for morbid obesity . since then
, obesity has become an epidemic with obesity rates of more than 20% in many states . with the advent of the laparoscopic technique in 1994 ,
bariatric surgery has continued to expand dramatically from 6868 cases in 1996 , 45473 cases in 2001 , to 103 000 cases by 2003 improved results have been documented with increased hospital volume and surgeon experience .
many methods for laparoscopic construction of both the gastrojejunal ( gj ) and jejunojejunal ( jj ) anastomoses have been described .
this represents a follow - up to our prior report describing the triple stapling technique for the jejunojejunostomy in 256 patients without incidence of obstruction or leak .
a retrospective analysis of patients from 10/01 to 12/04 who underwent laparoscopic roux - en - y gastric bypass ( lrygb ) utilizing the triple stapling technique was done .
the lrybg was performed by or under the supervision of the principal author ctf at a university affiliated program that maintains a fellowship in minimally invasive surgery .
briefly , a 25-mm circular eea anvil ( us surgical , norwalk , ct ) was introduced transorally and brought out through the gastric pouch staple line after creation of an approximately 15-cc to 30cc lesser curvature based gastric pouch . the triple stapling technique ( tst ) for the jejunojejunostomy ( jj ) was performed by utilizing 2 firings of a 45-mm to 2.5-mm stapler each 180 degrees apart followed by closure with a final 45-mm or 60-mm to 2.5-mm stapler ( us surgical , norwalk , ct ) or ( ethicon , cincinnati , oh ) .
the gastrojejunostomy ( gj ) was created using an antecolic antegastric right oriented roux limb .
patients were ambulated later on the day of surgery unless they were admitted to the intensive care unit ( icu ) .
a water soluble upper gastrointestinal ( ugi ) radiological study was done on the morning of postoperative day 1 .
demographic data , body mass index ( bmi ) , operative data , and postoperative course were documented .
follow - up was carried out at 1 week , 1 month , 3 months , 6 months , 1 year , and yearly thereafter .
patients mean age was 41.1 years ( range , 14 to 68 ) , mean bmi was 49.7 ( range , 35 to 91 ) and 82% were females .
one conversion to open ( 0.23% ) was necessary secondary to severe adhesions in a patient with 3 prior abdominal operations .
concomitant procedures performed included hiatal hernia repair in 16 patients ( 3.7% ) , cholecystectomy in 27 ( 6.2% ) , near total gastrectomy in 1 patient with a gastrointestinal stromal tumor , partial gastrectomy in 1 patient with an antral polyp , splenectomy for idiopathic thrombocytopenic purpura ( 1 ) , partial left hepatic lobectomy for a symptomatic hemangioma ( 1 ) , and partial small bowel resection ( 2 ) secondary to an unreducible intussusception ( 1 ) , and jejunal diverticulum ( 1 ) . postoperative day 1 ugi testing was negative in all cases . ultimately , however , 3 leaks occurred at the gj anastomosis ( 0.7% ) .
all 3 patients underwent reoperation on postoperative day 9 . despite prolonged hospitalization , all 3 patients survived .
one patient with a history of non - hodgkin 's lymphoma in remission ( 0.2% ) had emesis and underwent repeat ugi that exhibited lack of progression of contrast beyond the jj .
he underwent further reoperation twice with fascial biopsies and washout ; however , he eventually died on postoperative day 10 .
autopsy did not reveal an intra - abdominal or systemic source of infection or rhabdomyolysis .
patients required transfusion of an average of 2.21.1 units ( range , 0 to 5 ) , but none required surgical or endoscopic intervention .
the first was described above ; the other was a 68-year - old patient with renal failure on dialysis who underwent an uneventful surgery but died later the day of surgery from a cardiac arrhythmia .
gj stenosis occurred in 4 patients ( 0.9% ) and responded to endoscopic dilatation . in no circumstance was reoperation necessary .
the availability of laparoscopic bariatric surgery and its many benefits has been instrumental in the dramatic increase in the number of procedures .
the learning curve has been stated as 100 cases while nguyen et al have shown improved results with higher volume hospitals ( > 100 cases per year ) with regard to length of hospital stay , morbidity rate , and mortality rate .
most authors utilize a double stapling technique that places the roux limb at risk for stenosis and obstruction .
alternatively , many authors utilize a single stapling technique and subsequently close the enterotomy with a running suture .
we feel that the best method to minimize the risk of stenosis , obstruction , or leak is the above - described triple stapling technique .
creation of a wide side - to - side jejunojejunostomy and closure of the enterotomy in the center of this anastomosis has minimized the risk of stenosis or obstruction . it must be emphasized that particular attention must be given to avoid including the posterior wall when closing the enterotomy with the last firing of the stapler .
it remains unclear whether the cause of the afferent roux limb obstruction in this series was due to obstruction from a technical error or possibly secondary to an obstructing clot .
this patient had an unusual course with very high fevers reaching 107f despite negative cultures , muscle , and fascial biopsies and a negative autopsy .
the patient 's prior history of non- hodgkin 's lymphoma may be related to the patients deteriorating course and intense systemic inflammatory syndrome response .
we have thereafter been cautious in performing lrygb in patients with a prior history of treated malignant blood diseases .
internal herniation has been documented in up to 4.5% of cases after laparoscopic retrocolic roux - en - y gastrojejunostomy .
champion and williams documented a markedly reduced incidence of small bowel obstruction after changing from retrocolic to antecolic roux - en - y construction .
the orientation of roux limb in antecolic roux en - y gastric bypass has been shown to have significant impact .
changing from left to right orientation has decreased the rate of internal herniation from 9% to 0.5% .
the transection of the jejunal mesentery with only 1 staple firing also pulls the jj cephalad juxtaposed closely to the gj anastomosis anterior to the colon and may also further reduce the likelihood of internal herniation .
the absence of internal herniation in this series is therefore likely due to all of the abovementioned factors .
in addition , no leaks have occurred at the jj . because leaks and anastomotic dehiscence as far as 7 weeks postoperatively have been reported with the use of absorbable sutures ,
leaks may also occur if the staple lines are too close together or are placed parallel to each other , thus resulting in ischemia with subsequent necrosis .
the triple stapling technique utilizes coaxial followed by a perpendicular staple line and is therefore consistent and reproducible in avoiding ischemia and may be quicker in completing the jj .
the cause of the higher incidence of gi bleeding in this series is unclear because endoscopy is not used postoperatively secondary to concerns of disruption of the fresh anastomoses .
we have altered our dvt prophylaxis regimen as enoxaparin is now given beginning 12 hours postoperatively .
it is too early to know whether this will result in lower gi bleeding rates .
nevertheless , the intraluminal bleeding resolved spontaneously in each case with or without transfusion . in no case was reoperation necessary .
studies typically document a 1.6% to 20% stenosis rate . in a study by go et al , a stenosis rate of 6.8% occurred at an average of 7.7 weeks ( range , 3 to 24 ) postoperatively .
endoscopic dilatation was utilized an average of 2.1 times to relieve the stenosis with an ultimate 95% success rate and 3% complication rate that included 1 perforation . utilizing a 25-mm circular eea anvil placed transorally and brought out through the gastric pouch staple line
construction of the jejunojejunostomy utilizing the triple stapling technique is expeditious , safe , and associated with minimal complications .
 objective : to evaluate the outcomes of a single surgeon 's experience with laparoscopic roux - en - y gastric bypass ( lrygb ) utilizing the triple stapling technique for creation of the jejunojejunostomy.methods:a retrospective review of patients who underwent lrygb utilizing the triple stapling technique for creation of the jejunojejunostomy ( jj ) between 10/01 and 12/04 was performed.results:lrygb was performed in 435 consecutive patients . 
 the mean age was 41 years ( range , 14 to 68 ) , and 82% were female . 
 mean initial body mass index was 50 ( range , 35 to 91 ) . 
 one conversion to open ( 0.2% ) was necessary . mean operating time was 14426 minutes . 
 mean length of stay was 2.31.5 days . 
 there were 3 leaks at the gastrojejunostomy anastomosis ( 0.7% ) . 
 no leaks occurred at the jj anastomosis . 
 one patient underwent revision of the jj ( 0.2% ) secondary to obstruction of the jj on upper gastrointestinal study . 
 intraluminal bleeding occurred in 21 patients ( 4.8% ) . 
 patients required blood transfusion of 2.21.1 units ( range , 0 to 5 ) , but none required surgical or endoscopic intervention . 
 mortality occurred in 2 patients ( 0.5% ) . 
 mean excess body weight loss was 72% at 1 year.conclusion:construction of the jejunojejunostomy utilizing the triple stapling technique is expeditious , safe , and associated with minimal complication . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION