Reduction of surgical site infections after laparoscopic gastric bypass with circular stapled gastrojejunostomy

Background: Circular stapled gastrojejunostomy (GJ) is favored by many surgeons during lapa-roscopic Roux-en-Y gastric bypass (LRYGB). However, it has been associated with higher rates of surgical site infection (SSI). Objectives: To study the impact of introducing standard technical modifications (intervention) on the incidence of SSI after LRYGB with circular stapled GJ. Setting: Tertiary academic medical center. Methods: Consecutive patients who underwent primary LRYGB between May 2010 and September 2014 were separated into preintervention and postintervention cohorts. The intervention consisted of the use of a stapler cover, wound irrigation, antibiotic application to the wound, and primary wound closure. Predictor variables studied included patient demographic characteristics, the intervention, and other operative and perioperative factors. The primary outcome studied was SSI. Univariate and multivariate analyses were used to determine factors independently associated with SSI. Results: Three hundred thirty patients underwent LRYGB (preintervention n = 200, postintervention n = 130). Patients' characteristics were similar in both groups. A 21-mm stapler and chlorhexidine-based skin preparation were more frequently used in the postintervention group. SSI rate decreased from 15% to 3.8% (P < .01) after the intervention. On multivariate analysis, the intervention (OR .28, 95% CI .09-0.86, P = .026), use of chlorhexidine-based prep (OR .37, 95%CI .15-.93, P = .034), and maintenance of patient temperature (OR .47 95%CI .26-0.85, P = .012) were independently associated with reduced SSI rates. Conclusion: Use of a stapler cover, wound irrigation, wound antibiotic application, and primary wound closure were associated with a significantly lower wound infection rate after LRYGB with the circular stapled GJ. The observed SSI rates after our intervention are similar to those reported after hand-sewn and linear stapled techniques. In addition, other factors associated with decreasing the likelihood of developing SSI were use of chlorhexidine-based prep and maintaining intraoperative normothermia.