Hand-Sewn Running Barbed Suture versus Endoscopic Stapler Closure of the Mesenteric Defects in Retrocolic and Retrogastric RYGB: A Comparative Case-Matched Study

Abstract

Background: Obesity is nowadays a major health concern in Western countries and the number of bariatric surgical procedures being performed worldwide is vertiginously rising. The Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the gold standard bariatric procedure. The retrocolic retrogastric approach is closer to normal anatomy and it is associated to a lower rate of anastomotic leak, a lower rate of gastrojejunal stricture and a lower rate of marginal ulcers; therefore the problem of small bowel obstruction due to internal hernia (IH) has to be faced. The meticulous closure of all possible mesenteric defects with running, non-absorbable sutures may reduce the rate of this complication, but it can be challenging for the surgeon and it rises the operating time (OT). This study has conducted in a context of optimization of our “Fast Track-type” recovery protocol and it aims to compare the rate of early IH and the OT difference when mesenteric defects are closed using running non-absorbable barbed suture or an endoscopic stapler. Materials and Methods: From December 2014 to February 2015 a single-surgeon consecutive series of 22 patients undergoing retrocolic restrogastric LRYBP in our high volume obesity centre has been retrospectively extrapolated from our prospective longitudinal database. We recorded the overall OT and relative rate of IH in patients who received a 15-cm non-absorbable V-Loc TM 1 (group A, 11 patients) or Endopath TM EMS, endoscopic multifeed stapler 2 (group B, 11 patients) defect. Results: The mean OT was 77.36 minutes in the group A and 60.90 minutes in the group B (P value 0.066). 0 patients (0%) in the group A versus 4 patients (36.3%) in the group B developed IH within 30 days (two-tailed P value at chi-square test: 0.02). Conclusion: Early rate of small bowel obstruction due to IH is extremely higher with the use of an endoscopic stapler instead of non-absorbable barber suture and there is not significant difference in the OT; more prospective randomized trials observing bigger series of patients with longer follow-up are needed to validate our study.