roux - en - y gastric bypass is the technique of choice for the treatment of morbid obesity .
since the introduction of the laparoscopic approach by wittgrove et al , different ways to perform the same procedure have been described , gastrojejunostomy being one of the variable steps among surgeons .
it has been said that gastrojejunostomy diameter is very important for the results of this procedure , especially regarding excess weight loss ; however , in recent years some studies have shown that weight loss is independent of the anastomotic technique used . in this study
, we compare 2 different gastrojejunostomy techniques , performing the rest of the procedure in the same way .
this was a randomized controlled trial . from september 2005 to august 2006 , 80 consecutive patients with morbid obesity were scheduled for a laparoscopic roux - en - y gastric bypass ( lrygb ) .
patients were randomly assigned to 2 groups by the use of sealed envelopes . in group a ( n=40 ) , the gastrojejunostomy was performed with a 21-mm circular - stapler ( ethicon endo - surgery , cincinnati , ohio ) , and in group b ( n=40 ) this anastomosis was performed with a 45-mm linear - stapler ( ethicon endo - surgery , cincinnati , ohio ) . written consent was obtained from each patient , and the local ethics committee gave permission .
navarrete ) using a standard technique . the complete laparoscopic procedure has been previously described . in summary ,
an lrygb is performed with a 30-ml gastric pouch , antecolic gastric limb , and latero - lateral jejunojejunostomy with a 45-mm linear - stapler ( ls ) . for patients
whose body mass index ( bmi ) was less than 50 kg / m , we used a 100-cm gastric limb , and for those whose bmi was 50 kg / m , we used a 150-cm gastric limb . for group
a , the gastrojejunostomy was constructed by passing the anvil transorally using a nasogastric tube .
the handpiece of the circular - stapler ( cs ) is introduced directly through the abdominal wall and then passed into the gastric limb to perform the anastomosis . for group
b , a gastrotomy and an enterotomy were created to provide access for the stapler .
the legs of a 45-mm ls were introduced 18 mm into the gastric and jejunal lumina , and the stapler was fired to perform the gastrojejunostomy .
all patients had an abdominal drainage located in the left subhepatic space for 5 to 7 days after surgery .
oral fluids were started on the second postoperative day , and patients were discharged from the hospital when tolerance was good .
data were prospectively collected with emphasis in gastrojejunostomy complications , operative time , length of stay , and percentage of excess weight loss .
navarrete ) using a standard technique . the complete laparoscopic procedure has been previously described . in summary ,
an lrygb is performed with a 30-ml gastric pouch , antecolic gastric limb , and latero - lateral jejunojejunostomy with a 45-mm linear - stapler ( ls ) . for patients
whose body mass index ( bmi ) was less than 50 kg / m , we used a 100-cm gastric limb , and for those whose bmi was 50 kg / m , we used a 150-cm gastric limb . for group
a , the gastrojejunostomy was constructed by passing the anvil transorally using a nasogastric tube .
the handpiece of the circular - stapler ( cs ) is introduced directly through the abdominal wall and then passed into the gastric limb to perform the anastomosis . for group
b , a gastrotomy and an enterotomy were created to provide access for the stapler .
the legs of a 45-mm ls were introduced 18 mm into the gastric and jejunal lumina , and the stapler was fired to perform the gastrojejunostomy .
all patients had an abdominal drainage located in the left subhepatic space for 5 to 7 days after surgery .
oral fluids were started on the second postoperative day , and patients were discharged from the hospital when tolerance was good .
data were prospectively collected with emphasis in gastrojejunostomy complications , operative time , length of stay , and percentage of excess weight loss .
patient 's age and body mass index were similar in both groups ( table 1 ) , and the 2 main gastrojejunostomy complications were bleeding and stricture ; the latter was significantly more frequent in group a , p<0.05 ( table 2 ) .
patients who developed anastomotic stricture were successfully treated by endoscopic balloon dilation ; however , one patient ( group a ) presented with severe abdominal pain and pneumoperitoneum and a microperforation was diagnosed .
a relaparoscopy was done in this patient for abdominal lavage and drainage with good results .
one patient had a wound infection at the port site used for the extraction of the cs , which was successfully treated by wound opening and dressing .
distribution by age , sex , and body mass index ( bmi ) cs = circular - stapler ; ls = linear - stapler ; f = female ; m = male .
complications following 2 types of gastrojejunostomy techniques cs = circular - stapler ; ls = linear - stapler .
the operative time was 162 minutes on average in group a ( range , 120 to 300 ) , and 156 minutes on average in group b ( range , 90 to 270 ) , p>0.05 ; hospital stay was 3.2 days on average in group a ( range , 2 to 7 ) and 3.5 days on average in group b ( range , 2 to 6 ) , p>0.05 ( table 3 ) .
operative time ( ot ) and hospital stay ( hs ) cs = circular - stapler ; els = linear - stapler .
sixty - one patients ( 76.2% ) completed 1 year of follow - up , 33 in group a and 28 in group b , p>0.05 .
the percentage of excess weight loss at 1 year following surgery was 92.2% in group a ( range , 60 to 100 ) and 84.1% in group b ( range , 50 to 100 ) , p>0.05 .
since wittgrove et al described the first laparoscopic gastric bypass , many variations of the original technique have been reported .
our practice began following this technique step by step , and throughout our experience , we have made modifications .
some possible technical variations in the lrygb are the gastrojejunostomy technique , length and rout of the gastric limb , use of rings at the gastric pouch , and gastrostomy at the gastric remnant .
complications involving gastrojejunostomy ( stricture , bleeding , leaks , and fistulas ) frequently result in additional procedures and sometimes require hospital readmission .
we believe the best way to avoid these complications is to evaluate different techniques in a prospective manner .
our results are similar to those reported in the literature , the stricture being the most common complication of the gastrojejunostomy . in this study ,
the stricture rate was significantly higher with the 21-mm cs technique , which is consistent with previous reports .
in a recent paper , takata et al concluded that the use of a 21-mm cs was the only independent predictor of a gastrojejunostomy stricture in 379 patients who underwent roux - en - y gastric bypass with 4 gastrojejunostomy techniques ( hand - sewn , ls , 21-mm cs , and 25-mm cs ) .
our trial results support takata 's study , because we had a lower gastrojejunostomy stricture rate using the ls technique .
stricture incidence has been previously reported variously in 4% to 7% of patients with the ls technique , and our stricture rate was even lower ( 2.5% ) .
nonetheless , some of these authors do not accurately report the size of the anastomosis , which can vary according to the depth at which the stapler is introduced into the gastrojejunal opening .
also the stricture can be related to the technique used for closure of this opening ( stapled vs hand - sewn ) .
some authors have reported an increased frequency of wound infection with cs , related to the extraction of the contaminated hand piece through a port site . in our study ,
one patient in group a had a wound infection at this port site ; however , this does not represent a significant difference ( table 2 ) .
other complications related to the gastrojejunostomy like bleeding , ulcers , leaks , and fistula are present with all the techniques reported , without statistical differences , as occurred in our series .
some authors have reported a longer operative time with cs ; nevertheless , we found no difference between these techniques , perhaps due to our previous experience with cs , particularly in the passing of the transoral anvil .
one of the most important objectives of our work was to determine the percentage of excess weight loss with the 2 gastrojejunal anastomosis techniques .
it has been said that the size of the gastrojejunostomy is very important regarding excess weight loss , the bigger the anastomosis , the lesser the excess weight loss .
however abdel - galil et al did not find any difference in excess weight loss in 90 patients operated on with 3 different gastrojejunostomy techniques ( cs , ls , and hand - sewn ) .
also in a retrospective study , shope et al evaluated the weight loss between ls and cs gastrojejunal anastomosis with no differences found at 6-month and 8-month follow - up .
other studies have reported no differences in excess weight loss , comparing 21-mm with 25-mm cs used to perform the gastrojejunostomy . at 1-year follow - up
, we did not find statistically significant differences in excess weight loss between the 21-mm cs and the ls techniques ; however , a long - term follow - up is being carried out to confirm this issue .
complications , length of stay , and percentage of excess weight loss were similar between both techniques ; however , there was an increased incidence of stricture in the cs group ( 17.5% vs 2.5% , p<0.05 ) .
treatment of these strictures by endoscopic dilation showed very good results , but it is not free of complications .
both gastrojejunal anastomosis techniques ( cs-21 mm and ls ) are safe and effective ; however , the 45-mm liner - stapler is preferable because it has a lower stricture rate .
 objectives : we present a randomized controlled trial of laparoscopic gastric bypass comparing 2 techniques of gastrojejunostomy in patients with morbid obesity.methods:eighty consecutive patients underwent laparoscopic roux - en - y gastric bypass between september 2005 and august 2006 . 
 patients were randomly assigned to 2 groups by the use of sealed envelopes . in group 
 a , the gastrojejunal anastomosis was performed with a 21-mm circular - stapler , and in group b , this anastomosis was performed with a 45-mm linear - stapler . 
 the rest of the procedure was identical in both groups . 
 variables evaluated were complications involving the gastrojejunostomy , operative time , length of stay , and percentage of excess weight loss.results:both groups were similar in age and body mass index . 
 no patients experienced leakage or gastrojejunal anastomosis fistula , but group a patients had a more frequent stricture rate ( p<0.05 ) . 
 operative time and hospital stay were comparable in both groups ( p>0.05 ) . 
 percentage excess weight loss at one year following surgery was satisfactory in both groups , without a statistically significant difference ( p>0.05).conclusion : gastrojejunal anastomosis does not seem to be a critical factor in excess weight loss for morbidly obese patients who underwent laparoscopic gastric bypass . 
 the 2 techniques used in this experience are safe and effective ; however , the 45-mm liner - stapler is preferable because it has a lower stricture rate . 
INTRODUCTION
METHODS
Operative Procedure
RESULTS
DISCUSSION
CONCLUSION