The Effect of Route of Anvil Insertion on Stricture Rates with Circular Stapled Gastrojejunostomy During Laparoscopic Gastric Bypass

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.