Clinical Efficacy of Jejunojejunostomy Leak Test Using Methylene Blue During Laparoscopic Roux-en-Y Gastric Bypass on Post-Operative Leak Rate

Document Type : Research/Original Article


1 Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Obesity Prevention and Treatment Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

3 Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran

4 Health Policy Research Center, Shiraz University of Medical Sciences, Rasht, Iran

5 Private General Practitioner, Shiraz, Iran


Background: Obesity is becoming a worldwide health problem. Recently, bariatric surgeries are developing to combat with this
problem. However, these surgical methods themselves have risks.
Objectives: The present study investigated the preventive effect of routine leak test of both gastrojejunal and jejunojejunal anastomoses
immediately after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery against post-operative leak by inexperienced surgeons.
Methods: In a prospective interventional study, this research enrolled 52 morbid obese patients with LRYGB from September 2014
to October 2016. After anastomoses, methylene blue and air leak tests were performed and the section line and both anastomosis
sites for patency and inspected for air and dye leaks were examined.
Results: Mean body mass index of patients was 48.846.8 kg/m2. Twelve patients had positive leak test and the anastomoses were
reinforced by additional sutures. All patients were discharged with no leak and no patient had leak during the routine follow-up
Conclusions: Intraoperative leak test of both gastrojejunal and jejunojejunal anastomoses is a valuable test in the assessment of
leak during LRYGB surgery, especially in unskilled surgeons.


1. Alam I, Agrawal S. Introduction to obesity. In: Agrawal S, editor. Obesity, bariatric and metabolic surgery: a practical guide. 1st ed. Springer International Publishing; 2015. p. 3–11.
2. Rojhani-Shirazi Z, Amini M, Meftahi N, Sepehrimanesh M, Poorbaghi SL, Vafa L. Comparison of anthropometric measures in people with and without short- and long-term complications after laparoscopic sleeve gastrectomy.Comparat Clin Pathol. 2017;26(6):1375–9. doi: 10.1007/s00580-017-2543-y.
3. Berbiglia L, Zografakis JG, Dan AG. Laparoscopic Roux-en-Y gastric bypass: surgical technique and perioperative care. Surg Clin North Am. 2016;96(4):773–94. doi: 10.1016/j.suc.2016.03.003. [PubMed: 27473801].
4. Higa KD. Laparoscopic gastric bypass: technique and outcomes. In: Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ, editors. The ASMBS textbook of bariatric surgery. 2 ed. Iowa City: Springer; 2015.
5. Schweitzer MA, Lidor A, Magnuson TH. A zero leak rate in 251 consecutive laparoscopic gastric bypass operations using a two-layer gastrojejunostomy technique. J Laparoendosc Adv Surg Tech A. 2006;16(2):83– 7. doi: 10.1089/lap.2006.16.83. [PubMed: 16646693].
6. Fullum TM, Aluka KJ, Turner PL. Decreasing anastomotic and staple line leaks after laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2009;23(6):1403–8. doi: 10.1007/s00464-009-0370-1. [PubMed: 19263134].
7. Masoomi H, Kim H, Reavis KM, Mills S, Stamos MJ, Nguyen NT. Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass. Arch Surg. 2011;146(9):1048–51. doi: 10.1001/archsurg.2011.203. [PubMed: 21931002].
8. Pooli A, Phillips E. Prevention of anastomotic leaks in bariatric surgery. Bariatr Time. 2010;7(3):8–13.
9. Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, Sugerman H, et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg. 2007;11(6):708–13. doi: 10.1007/s11605-007-0085-3. [PubMed: 17562118].
10. Perez A, DeMaria EJ, Portenier DD, Grant JP, Pryor AD. W1701 gastrojejunal (GJ) leak after laparoscopic Roux-en-Y gastric bypass (LRYGB) carries minimal risk with an aggressive detection / management approach, whereas greater morbidity / mortality occurs with leak at the jejunojejunostomy (JJ). Gastroenterol. 2008;134(4):A–909. doi: 10.1016/s0016-5085(08)64272-9.
11. Smith MD, Adeniji A, Wahed AS, Patterson E, Chapman W, Courcoulas AP, et al. Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015;11(2):313–20. doi: 10.1016/j.soard.2014.05.036. [PubMed: 25595919]. [PubMed Central: PMC4425611].
12. Mohos E, Schmaldienst E, Richter D, Prager M. Examination of the efficacy and safety of intraoperative gastroscopic testing of the gastrojejunal anastomosis in laparoscopic Roux Y gastric bypass surgery. Obes Surg. 2011;21(10):1592–6. doi: 10.1007/s11695-011-0428-8. [PubMed: 21538176].
13. Alaedeen D, Madan AK, Ro CY, Khan KA, Martinez JM, Tichansky DS. Intraoperative endoscopy and leaks after laparoscopic Roux-enY gastric bypass. Am Surg. 2009;75(6):485–8. discussion 488. [PubMed: 19545096]. 
14. Fernandez AZ, DeMaria EJ, Tichansky DS, Kellum JM, Wolfe LG, Meador J, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004;18(2):193–7. doi: 10.1007/s00464-003- 8926-y. [PubMed: 14691697].
15. Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, et al. First report from the American college of surgeons bariatric surgery center network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20. discussion 420-2. doi: 10.1097/SLA.0b013e31822c9dac. [PubMed: 21865942]. [PubMed Central: PMC3339264].
16. Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM, American Society for M, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11(4):739–48. doi: 10.1016/j.soard.2015.05.001. [PubMed: 26071849].
17. Cingi A, Yavuz Y. Intraoperative endoscopic assessment of the pouch and anastomosis during laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2011;21(10):1530–4. doi: 10.1007/s11695-011-0355-8. [PubMed: 21229330].
18. Al Hadad M, Dehni N, Elamin D, Ibrahim M, Ghabra S, Nimeri A. Intraoperative endoscopy decreases postoperative complications in laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2015;25(9):1711–5. doi: 10.1007/s11695-015-1604-z. [PubMed: 25663175].
19. Geubbels N, de Brauw LM, Acherman YI, van de Laar AW, Wouters MW, Bruin SC. The preceding surgeon factor in bariatric surgery: a positive influence on the learning curve of subsequent surgeons. Obes Surg. 2015;25(8):1417–24. doi: 10.1007/s11695-014-1538-x. [PubMed: 25511752].
20. Sanchez-Santos R, Estevez S, Tome C, Gonzalez S, Brox A, Nicolas R, et al. Training programs influence in the learning curve of laparoscopic gastric bypass for morbid obesity: a systematic review. Obes Surg. 2012;22(1):34–41. doi: 10.1007/s11695-011-0398-x. [PubMed: 21455832].
21. Celio AC, Kasten KR, Burruss MB, Pories WJ, Spaniolas K. Surgeon case volume and readmissions after laparoscopic Roux-en-Y gastric bypass: more is less. Surg endosc. 2017;31(3):1402–6.
22. Hsu GP, Morton JM, Jin L, Safadi BY, Satterwhite TS, Curet MJ. Laparoscopic Roux-en-Y gastric bypass: differences in outcome between attendings and assistants of different training backgrounds. Obes Surg. 2005;15(8):1104–10. doi: 10.1381/0960892055002374. [PubMed: 16197780].
23. Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–42. doi: 10.1056/NEJMsa1300625. [PubMed: 24106936].