Staplerless Laparoscopic Gastric Bypass: Not So Fast

Abstract

© FD-Communications Inc. Obesity Surgery, 16, 2006 1115 We read with interest the article by Ettinger and colleagues1 presenting a series of patients submitted to laparoscopic Roux-en-Y gastric bypass (LRYGBP) without using staplers. The author carefully described a procedure, including very instructive illustrations and pictures, where they use an electrothermal bipolar vessel sealer (LSA) (LigaSure Atlas®, Valleylab, Tyco, Boulder, CO) to replace the endostaplers, in order to reduce costs. The authors have performed 82 operations since 2004, and presented the data from the first 30 patients, reporting no major surgical complications using this novel technical approach. Our group has performed over 600 LRYGBPs and has acquired a large experience with the hand-sewn technique that we routinely use for the gastrojejunal anastomosis, selective staple-line oversuture, closure of stapler openings and repair of mesenteric defects. We have had 1.2% pouch leaks and only one case (0.2%) of leak of the gastrojejunal anastomosis. Last year we assumed that we were sufficiently skilled2 and performed our first staplerless procedure on a 24-year-old woman with BMI 37 kg/m2, gynecoid obesity, with the following co-morbidities: arterial hypertension, hepatic steatosis, dislipidemia, insulin resistance and knee arthritis. The procedure was successfully completed in 180 minutes, but on postoperative day 4, she developed abdominal pain and signs of systemic inflammatory response. She was submitted to relaparoscopy to treat leaks in the gastrojejunal anastomosis and excluded stomach, and a second intervention 3 weeks later to drain a pelvic abscess. The patient was discharged 40 days after the primary surgery, and the total medical costs were 107,470.00 US dollars. Our thoughts after this first case were: 1) the technique is cumbersome and time-consuming; 2) the thermal damage to thicker tissues like the stomach may go beyond the 2 mm suggested by the manufacturer when sealing vessels; 3) the potential advantage of avoiding leaks and fistulas may not be consistent overall; 4) the reductions in cost may not be worth it if complication rates increase; 5) surgeons must be cautious because the LSA device was neither designed nor tested for this type of application.3 Finally, we challenge the conclusion by the authors when they state that the ideal equipment that seals, cuts and sutures is still to be developed by the industry. In our opinion, the endostaplers are properly fulfilling their roles and have been improved over time.4 Furthermore, the stapler costs tend to decrease as LRYGBP becomes the gold standard operation for the treatment of morbidly obese patients.5