Double application of TA-90 B four-row AutoSuture(R) stapling instrument: A safe, effective method of staple-line production indicated by follow-up GI series

Background: Controversy continues concerning the best method of isolating upper and lower gastric pouches in Roux-Y gastric bypass. This paper reports a technique used from August 1991 through May 1996, in which there was a double application of the TA-90 B Four-Row AutoSuture(R) Stapling Instrument to form the proximal gastric pouch. Because of a significant staple-line failure rate historically, many are separating the pouches. However, due to recent reports of gastro-gastric fistula formation when pouch separation is done, a second look has been taken at stapling the division without separation of the pouches. Methods: There were 650 patients in this series, and 160 asymptomatic patients 1-4 years postoperatively agreed to have limited upper GI series. Results: Only one of this group had staple-line failure. Failures were seen in four of 19 symptomatic patients with dyspepsia or rapid weight regain. Putting these two groups together, our staple-line failure rate has been less than 1% using this technique. Conclusion: Whether stapling in continuity or dividing the stomach, the two methods appear to be equally effective with comparable morbidity. Patients with staple-line failure or gastro-gastric fistulae will ultimately be forced by their symptoms of rapid weight regain and/or peptic ulcer disease and reflux esophagitis to return for follow-up. Asymptomatic patients very rarely have a connection between upper and lower pouches, and routine follow-up upper GI series are not indicated.