Introduction 1 2 3 4 3 5 6 7 8 10 11 3 12 15 3 9 13 14 16 17 12 16 19 19 20 19 20 N 20 20 specifically for stricture Patients and Methods Patients A consecutive series of morbidly obese patients underwent LRYGB between November 12, 2001, and February 28, 2006 (51 months), in a dedicated, community-based, bariatric program awarded Center-of-Excellence status by the Surgical Review Corporation in 2005. N N Helicobacter pylori Surgical Technique 10 2 2 2 Patients who experienced persistent postoperative nausea, vomiting, and intolerance to solid food were referred for upper gastrointestinal studies, followed by referral to the gastroenterologist for upper endoscopy. Patients with stricture were treated endoscopically with balloon dilation to a maximum of 15 mm. Statistical Methods 1 Table 1 Univariate Analysis to Identify Preoperative Patient Characteristics Associated with Stricture Variable N N P N 92 1,259  Age, mean (SD) 41.4 (11.6) 44.4 (10.4) a Cardiac disease 6 (6.5) 107 (8.5) 0.885 Chronic depression 21 (22.8) 278 (22.1) 0.634 Chronic respiratory disease 22 (23.9) 318 (25.3) 0.766 Chronic venous insufficiency 53 (57.6) 692 (55.0) 0.347 Degenerative joint disease 89 (96.7) 1,209 (96.0) 0.893 Diabetes, type 2 26 (28.3) 307 (24.4) 0.184 N – – 0.145  Caucasian 76 (82.6) 1,122 (89.1) –  Other 16 (17.4) 137 (10.9) – GERD 66 (71.7) 715 (56.8) a N – – 0.208  Female 81 (88.0) 1,042 (82.8) –  Male 11 (12.0) 217 (17.2) – Hypercholesterolemia/hyperlipidemia 40 (43.5) 624 (49.6) 0.958 Hypertension 41 (44.6) 652 (51.8) 0.838 Infertility 11 (12.0) 96 (7.6) 0.732 Nonsteroidal anti-inflammatory medications 17 (18.5) 294 (23.4) 0.284 No. preoperative comorbidities 5.2 (2.0) 5.1 (1.9) 0.259 No. preoperative medications 4.6 (3.6) 4.2 (3.5) 0.088 Obstructive sleep apnea 43 (46.7) 564 (44.8) 0.415 BMI 48.5 (8.5) 49.2 (8.3) 0.202 Fasting blood sugar 111.5 (45.4) 108.9 (39.6) 0.779 HbA1C 6.2 (1.8) 6.1 (1.2) 0.150 Previous abdominal surgeries 1.2 (1.1) 1.2 (1.3) 0.754 Urinary stress incontinence 52 (56.5) 698 (55.4) 0.322 a P t P P In the initial analysis of preoperative characteristics by univariate logistic regression, age, number of comorbidities, number of medications, BMI, fasting blood sugar, HbA1C, and previous abdominal surgeries were classified as continuous variables. With the exception of sex and ethnicity (dichotomized to male/female and Caucasian/non-Caucasian, respectively), all remaining variables were dichotomized (yes/no). In the final multivariate forward stepwise logistic regression model, both age and BMI were redefined as categorical variables: age was coded to reflect four levels (≤35, 36 to 45, 46 to 55, and ≥55 years) and BMI was coded to reflect two levels (<50 and ≥50). Results 2 Operative technique was the same in all procedures, namely, a retrocolic, retrogastric, transoral, 21-mm, circular stapled gastrojejunostomy. Mean intraoperative time was 96 min and length of stay averaged 2.8 days; 97.6% of operations were accomplished laparoscopically and 2.4% were conversions to open procedures. There were two reoperations with revision of the gastrojejunostomy in the “stricture group.” The first was in a patient who developed a leak immediately postoperatively and returned to the OR for definitive management. The patient developed a stricture that was not amenable to dilation and, at 7 months, underwent a revision of her gastrojejunostomy. The second patient had a stricture that was dilated to 12–15 mm. Subsequent endoscopy showed no recurrent stricture. She continued to eat very large portions in multiple meals, developing recurrent bezoars that had to be cleared endoscopically. The pouch dilated over time, and even though the gastrojejunostomy was shown to be only large enough to pass an endoscope, we were obliged to revise the pouch to a smaller size. Since that time she has had no further problem with bezoars. 1 20 2 Table 2 Forward Stepwise Multivariate Logistic Regression Model for Complications of Stricture Variable N P Odds Ratio (95% Confidence Interval) Stricture Group Nonstricture Group 30-day readmission 27 (29.35%) 109 (8.66%) a 4.381 (2.666–7.197) Cholecystectomy 6 (6.52%) 38 (3.02%) 0.181 NS Internal hernia 1 (1.09%) 35 (2.78%) 0.337 NS Small bowel obstruction 4 (4.35%) 24 (1.91%) 0.500 NS Intra-abdominal abscess 3 (3.26%) 25 (1.99%) 0.691 NS Peripheral neuropathy 5 (5.43%) 6 (0.48%) a 11.979 (3.423–41.929) Infection 2 (2.17%) 2 (3.57%) 0.151 NS a Mean percent excess weight loss at 1 year following surgery was the same for both groups (−103.1 lb, 82.6% stricture group vs −115.8 lb, 82.0% nonstricture group). Mean numbers of medications were reduced from 4.6 to 1.6 and from 4.2 to 1.5 in the stricture and nonstricture groups, respectively, at the most recent postoperative examination. P P P 1 P P 3 P P Table 3 Significance and Odds Ratios for Age, GERD, Gender, and BMI in Multivariate Models to Predict Stricture Variable P Odds Ratio (95% Confidence Interval) a  Age b 0.973 (0.953–0.993)   GERD b 1.917 (1.200–3.062)  Gender 0.324 NS  Preoperative BMI 0.086 NS c  Age overall 0.015    Group 1: ≤35 years (reference category)  1   Group 2: 36–45 years 0.015 0.508 (0.294–0.877)   Group 3: 46–55 years 0.004 0.431 (0.244–0.760)   Group 4: >55 years 0.126 0.596 (0.308–1.156)  GERD 0.005 1.963 (1.227–3.141)  Gender 0.353 NS  Preoperative BMI 0.100 NS a b c 3 P P P P P P P P P 2 Discussion Strictures contribute to almost half of all readmissions in the early perioperative period and require instrumentation and rehydration. They can also be associated with the development of a more serious complication, peripheral neuropathy, as is demonstrated by these data. 20 H. pylori 2 2 older age Our original assumption that higher rates of central fat distribution in males might place greater tension on the anastomosis predisposing male patients, particularly those with higher BMIs, toward stricture, may be in error. The effect of increased central fat on the anastomosis may not be injurious if meticulous technique is used to ensure a tension-free anastomosis. Also, the ischemic effects of diabetes, sleep apnea, and chronic respiratory disease at the gastrojejunostomy site may be insufficient, in themselves, to cause stricture. It has been well documented that operative technique can contribute to increased stricture rates. Previous studies have reported fewer strictures with hand-sewn anastomoses than with stapled ones. Some authors have demonstrated that the 25-mm EEA stapler may be associated with fewer strictures that the 21-mm EEA stapler; we have a 6.8% stricture rate with the 21-mm EEA stapler. Further studies of stapling methodologies are warranted. 21 22 not 2 2 The objective of this study was to reach back in the causal continuum, prior to the intraoperative effects of technique and surgeon experience, to identify other potentially salient contributors to postoperative stricture. This analysis of a large series of patients undergoing RYGB identified GERD and age as factors associated with gastrojejunostomy stricture. Conclusions Using absorbable suture at the gastrojejunostomy anastomosis appears to decrease stricture rates. As identified via multivariate logistic regression analysis, GERD and age are independent predictors of gastrojejunostomy stricture.