Bioabsorbable Staple Line Reinforcement and the Prevention of Strictures and Marginal Ulcers

Thomas D Martin, MD, Kirstie S Van Ry, MD, Dimitri Stefanidis, MD, PhD, Timothy S Kuwada, MD, Keith S Gersin, MD. Carolinas Medical Center

Introduction: Gastrojejunal anastomotic (GJA) ulcers and strictures occur in up to 3-31% and 0.6-16% of patients respectively after laparoscopic Roux-en-Y gastric bypass (LRYGB), and may lead to significant morbidity. The purpose of this study was to evaluate the impact of bioabsorbable staple line reinforcement on the GJA stricture and marginal ulcer rates. We hypothesized that reinforcement would decrease the incidence of marginal ulceration and anastomotic strictures.

Methods: Retrospective review of prospectively collected data on consecutive patients undergoing LRYGB before and after the introduction of GORE Seamguard® circular reinforcement between March 2012 and August 2014. All procedures were performed by one surgeon using identical techniques and equipment. A transgastric 25 mm EEA stapler (Ethicon Endosurgery, Cincinnati, OH) was used for all gastrojejunal anastomoses. Post-operative endoscopic procedures were completed by the same surgeon; indications included severe dysphagia or GERD symptoms unresponsive to pharmacologic therapy. Marginal ulcers were defined as those seen on endoscopy. Anastomotic strictures were defined as requiring pneumatic balloon dilation. Patient characteristics including age, gender, BMI, co-morbidities, and subsequent endoscopic findings were recorded. Marginal ulceration and anastomotic stricture rates were compared between the two groups, those with and without Seamguard® reinforcement. Time from operation to endoscopic diagnosis of anastomotic stricture or marginal ulcer was also analyzed.

Results: 95 patients had Seamguard® reinforcement of the GJA while 105 did not during the study period. The patient characteristics between the two groups were similar. Marginal ulcer rate in the reinforced group was 8.4% compared to 8.9% in the unreinforced group (p=0.9) and anastomotic stricture rates were 4.2% and 5%, respectively (p>0.9). Three patients in the unreinforced group developed concomitant marginal ulcers and anastomotic strictures whereas no patients in the reinforced group developed both complications. Average time from operation to endoscopic diagnosis of anastomotic strictures was 75 days in the reinforced group compared to 78 days (p=0.8) in the unreinforced group; for marginal ulcers average time was 109 days versus 85 days, respectively (p=0.5).

Conclusion: In our experience, the use of circular bioabsorbable staple line reinforcement at the gastrojejunal anastomosis during LRYGB did not reduce rates of anastomotic stricture or marginal ulceration. There were no anastomotic bleeding complications in either group. Given the limited number of patients, a larger sample size may be needed to detect a difference between the two groups. More evidence is needed to determine the value of GJA reinforcement.

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