The Incidence of Gastrojejunostomy Ulceration After MGB-OAGB: Comparison of Hand-Sewn and Stapled Techniques of Anastomosis Formation. Multicenter Prospective Randomized Clinical Trial Study

Today, MGB-OAGB, a mini-gastric bypass or one anastomosis gastric bypass, is one of the most widely used bariatric procedures. This surgery was first performed by Professor R. Rutledge in 1997, having published the first data in 2001 on a sample of 1274 patients [1]. In 2014, the first consensus conference was held, at which recommendations for application and generalization of experience were adopted [2]. By 2018, the share of MGB-OAGB surgeries in the world was already 7.7% [3]. In the Russian Federation, this index for 2021 was 12%, which indicates a significant prevalence of mini-gastric bypass surgery in the Russian Federation [4]. This is facilitated by the simplicity, safety and high efficiency of this procedure in relation to obesity and metabolic disorders. Comparative studies and subsequent meta-analyses show a number of advantages over the classic Roux-en-Y gastric bypass [5, 6]. Reduction in the duration of the surgery and the reduction in the number of surgical complications are attractive for surgeons.

However, with the increase in the number of surgeries and the accumulation of experience, a number of problems associated with this surgery become apparent. Malabsorption risks are minimized by measuring the length of the common loop and cutting off a strictly defined percentage of the small intestine from digestion. Research on bile reflux effects is currently ongoing, but in order to reduce it, the surgical technique has been modified by lengthening the gastric tube [2]. One of the most serious problems is the appearance of gastrojejunostomy (GJS) ulcers. As a rule, they are difficult to treat and can cause bleeding. Their number seriously varies in different publications from 2% to 13% [7, 8]. These figures, despite the attractiveness of the new surgery, make many surgeons refrain from performing MGB-OAGB in their routine practice. The causes of ulcers are not fully understood and require further study, and it is also possible to change the technique of anastomosis.

Working Hypothesis We assume that the frequency of gastrojejunostomy ulcers after MGB-OAGB is associated with the peculiarities of the side-to-side GJS formation, which is currently the "gold standard" for this procedure. The geometry of such anastomosis leads to the formation of a narrow strip of the gastric wall between two stapler lines (between the suture from the 2nd cassette during the formation of the "small ventricle" and directly from the suture from the cassette during the GJS formation). Perhaps this section of the stomach wall is prone to ischemia, which can certainly increase the risk of ulcer formation. It is also possible that a zone with impaired blood supply may also form in the "blind pocket" above the anastomosis.

When forming a Hand-sewn GJS of the end-to-side type, ischemia zones do not occur. The anastomosis has a more physiological geometry, there is no conflict between the lines of stapled sutures.

Thus, we put forward the assumption that a serious risk factor for the development of a GJS ulcer was eliminated when switching to a completely Hand-sewn technique for the GJS formation when performing MGB-OAGB.