Marta Penna et al. had performed a meta-analysis comparing linear-stapled versus circular-stapled laparoscopic gastrojejunal anastomosis in morbid obesity, in which nine trials were included comprising 9374 patients (2946 linear vs. 6428 circular) [10]. Primary outcome analysis revealed a statistically significant increase in the rate of GJ stricture associated with CSA with a significantly reduced rate of wound infection, bleeding, and operative time associated with LSA hence recommending the preferential use of the linear stapling technique over circular stapling.

LSA requires closure of the enterotomy site using hand-sewn anastomosis, which can be either longitudinal or transverse closure. Mueller et al. compared these two techniques retrospectively and noticed that the rate of GJ stricture was 16.5 % with longitudinal closure compared to 0 % in the transverse technique [11].

Lois AW et al. retrospectively reviewed 190 patients for GJA complication after LRYGB, performed by two surgeons comparing hand-sewn anastomosis (HSA) versus CSA [12]. The CSA technique had significantly higher rate of non-life threatening anastomotic complications compared to the HSA technique. Operative times were also significantly longer for HSA, with the length of hospital stay and long-term weight loss being no different. A recent RCT by Abellan et al. had shown no differences in the incidence of stricture or other complications between the two groups [13].

The rates of stricture formation have been 3–8 % with HSA, 0–6 % with LSA and 5–31 % with CSA. But majority of the strictures with the circular stapled technique have been with the 21 mm stapler [1, 5–7, 14–18]. Qureshi et al. reported a case-series, of 860 consecutive patients undergoing LRYGB using HSA, LSA, and CSA techniques at a single institution, with three different surgeons [19]. Each surgeon used only one of the three primary LRYGB technique already passing the learning curve, with experience of more than 100 cases. It was concluded that the CSA as the best overall GJA technique with lower rate of strictures.

Lee S et al. had shown that there was no difference in the three different techniques, with the linear technique having the lowest requirement for dilatation [20]. The comparison of all the three techniques by Bendewald FP et al. did not show any difference amongst the techniques [21]. A meta-analysis by Giordano et al. showed that the use of linear stapler compared to circular stapler was associated with a reduced risk of anastomotic stricture [22].

Leyba JL et al. conducted a randomized control trial to compared 21-mm circular-stapler and linear-stapler GJA. A significantly higher rate of stricture was noted in the 21-mm CSA group [5]. The operating time and hospital stay were comparable in both groups with the percentage excess weight loss at 1 year following surgery being no different. Similar results were shown by Gould JC et al. where the stricture rate was higher with the 21-mm CSA comparing to the 25-mm CSA [6].

Hence, most surgeons prefer to use a 25 mm circular stapler because of the higher incidence of stricture with the use of 21 mm stapler [1, 5, 7, 14–17]. But it has been recently shown that with technical modification of using the anvil trans-orally and at the level of the stapler line, the ischaemia can be reduced with lower stricture rates [23]. And with no differences in weight loss outcomes between usage of 21 and 25 mm stapler, it is reasonable to use 25 mm stapler when circular staplers are preferred [16, 18, 24].

Since the results amongst the various techniques being conflicting, no technique can be considered superior to the other except that 21 mm circular stapling technique having a higher stricture rate, the choice of the technique should be based on individual surgeon’s preference.

Endoscopic dilatation has become the primary treatment modality for the treatment of GJ stricture following RYGB, due to the reproducibility and low morbidity associated with the procedure. However there are no well-designed studies indicating this to be the best treatment method and no consensus exist on the safety of this. A review of literature of 23 studies containing 760 patients with GJ stricture showed a 98 % success rate with endoscopic interventions [25]. No guidelines exist on whether the Savary-Gillard bougie or the through the scope (TTS) balloon is better. But most studies have reported the use of TTS with S-G dilators being rarely used. The smallest diameter of the balloon used was 6 mm and the largest being 25 mm. An initial size of 12 mm seems to be the best option [25]. Huang et al. proposes a size of 15 mm to be optimal to prevent recurrences also keeping the chances of perforations lower [26, 27]. Even 15 mm is not without risks as perforations have been reported with this approach too [28]. The procedures were most commonly performed as an out-patient procedure under conscious sedation. There exists no recommendation for the duration of dilatation to be used. Most authors used dilatation from 1 min upto 3 min. The mean number of dilatations required was 1.7/patient. But most patients had a clinical resolution after a single procedure [25]. Contrast studies can be used selectively if patients showed any sign of possible perforation. The gastroscope has to be passed through the gastrojejunal anastomosis in all patients after dilation.