Staple-line reinforcement with bovine pericardium in laparoscopic sleeve gastrectomy: experimental comparative study in pigs

The effects of reinforcement methods on burst pressure in resected sleeve gastrectomy specimens

BACKGROUND

Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of two supportive techniques on burst pressures in sleeved gastrectomy specimens.

MATERIALS AND METHODS

Thirty patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into three groups. Group 1 had no extra support in the staple line, Group 2 had oversewing with continuous suture on the staple line, and Group 3 had fibrin sealant (Tisseel(®); Baxter, Deerfield, IL) on the staple line. The end point was the first detectable leakage, at which point leak pressure and the anatomic site of leakage were recorded.

RESULTS

Thirty sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences among group in terms of age, sex, and body mass index. The leak pressure was significantly higher (106±10.5 mm Hg) in Group 2 (P<.01). Leaks occurred significantly more frequently in the staple line than in the staple junction points (P=.014).

CONCLUSIONS

Oversewing the staple line with 3-0 Vicryl(®) (Ethicon, Somerville, NJ) suture significantly increased the strength of the staple line. Increases in intraluminal pressure are known to be one of the significant risks in leak etiology. Thus, we concluded that oversewing the staple line with 3-0 Vicryl suture can be beneficial in the prevention of leaks. However, further work is necessary in this area of research.

[Bursting pressure comparison between stapler and staple line reinforcement with sutures and butress biologic material: an experimental study]

BACKGROUND

Staple line leaks carry significant morbidity and mortality. Reinforcement is controversial. Several staple techniques have been described for this purpose. Oversuture and butressing material are more common.

AIM

To compare these two ways of reinforcement and staple line without any reinforcement regarding the bursting pressure.

METHOD

Ten segments of small bowel were created in a pig under general anesthesia. The bowel was inflatted until burst point and the pressure was measured.

RESULTS

The staple line bursting pressure was 94 mmHg +/- 18,52mmHg in the stapler technique; 87,5 mmHg +/- 18,59mmHg in the oversuture and 83,33 mmHg +/- 23,04mmHg with Surgisis®. There was no statistic difference among the techniques.

CONCLUSIONS

Oversuture or Surgisis® use did not increase the staple line resistance in pig.

Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate-PHASIX Mesh) in a Porcine Model of Hernia Repair

Purpose. Poly-4-hydroxybutyrate (P4HB) is a naturally derived, absorbable polymer. P4HB has been manufactured into PHASIX Mesh and P4HB Plug designs for soft tissue repair. The objective of this study was to evaluate mechanical strength, resorption properties, and histologic characteristics in a porcine model. Methods. Bilateral defects were created in the abdominal wall of n = 20 Yucatan minipigs and repaired in a bridged fashion with PHASIX Mesh or P4HB Plug fixated with SorbaFix or permanent suture, respectively. Mechanical strength, resorption properties, and histologic characteristics were evaluated at 6, 12, 26, and 52 weeks (n = 5 each). Results. PHASIX Mesh and P4HB Plug repairs exhibited similar burst strength, stiffness, and molecular weight at all time points, with no significant differences detected between the two devices (P > 0.05). PHASIX Mesh and P4HB Plug repairs also demonstrated significantly greater burst strength and stiffness than native abdominal wall at all time points (P < 0.05), and material resorption increased significantly over time (P < 0.001). Inflammatory infiltrates were mononuclear, and both devices exhibited mild to moderate granulation tissue/vascularization. Conclusions. PHASIX Mesh and P4HB Plug demonstrated significant mechanical strength compared to native abdominal wall, despite significant material resorption over time. Histological assessment revealed a comparable mild inflammatory response and mild to moderate granulation tissue/vascularization.

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial

BACKGROUND

The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG.

METHODS

From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C.

RESULTS

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6 ± 9.2 (range, 28-64) years. Mean preoperative body mass index was 47.2 ± 6.6 (range, 40-66) kg/m². Mean time for SLR was longer in group A (14.2 ± 4.2 (range, 8-18) minutes) compared with group B (2.4 ± 1.8 (range, 1-4) minutes) and group C (4.4 ± 1.6 (range, 3-6) minutes; P < 0.01). Four major complications were observed (3.3 %): one leak and one bleeding in group A; one bleeding in group B; and one leak in group C, with no significant differences between the groups. No mortality was observed.

CONCLUSIONS

SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.

Sleeve gastrectomy induces weight loss in diet-induced obese rats even if high-fat feeding is continued

BACKGROUND

Sleeve gastrectomy (SG) has been used for the surgical treatment of morbid obesity as a first or definitive procedure with satisfactory results. The objective of this study in rats was to establish the effects of SG on weight loss depending on the post-surgical type of diet followed.

METHODS

Thirty male Wistar rats were fed ad libitum during 3 months on a high-fat diet (HFD) to induce obesity. After this first phase, rats were subdivided in three groups of ten rats each and underwent a sham intervention, an SG, or no surgery but were pair-fed to the amount of food eaten by the animals of the SG group. At this time point, half of the animals in each group continued to be fed on the HFD, while the other half was switched to a normal chow diet (ND). Thus, the following subgroups were established: sham-ND, sleeve-ND, pair-fed-ND as well as sham-HFD, sleeve-HFD, and pair-fed-HFD. Body weight and food intake were recorded daily for 4 weeks. The feed efficiency rate (FER) was determined from weekly weight gains and caloric consumption during this period.

RESULTS

Statistically significant (P < 0.05) differences in body weight were observed between the six experimental groups after 4 weeks of the interventions with rats in the sleeve-ND group experimenting the highest weight loss (-78.2 ± 10.3 g) and animals in the pair-fed-HFD group exhibiting the lowest weight reduction (-4.0 ± 0.1 g). Interestingly, the FER value of rats that underwent the SG and continued to be fed on a HFD was significantly (P < 0.05) lower than that of sham operated and pair-fed animals on the same diet.

CONCLUSION

The positive effects of SG on weight reduction are observed in obese rats submitted to the intervention and subsequently following an ND or even an HFD.

A new biodegradable adhesive for protection of intestinal anastomoses. Preliminary communication

BACKGROUND AND AIMS

Anastomotic leaks continue to be a devastating complication for patients and surgeons worldwide. The few surgical adhesives available to date have not achieved the desired clinical results. The purpose of this experimental study was to determine if Pebisut® applied to intestinal suture lines provides increased resistance and protection during the critical days of healing.

METHODS

Intestinal lesions were caused in rats and dogs and a new biodegradable adhesive (Pebisut®) (patent granted in the European Union 07808494.4-1219, 01.12.2010, in Mexico P.C.T./MX/a/2009/001737, 16.02.2009, pending in the U.S.P.T.O. 60/762,136, 26.01.2006) was applied to compare the resistance of suture lines using bursting pressures and histologically.

RESULTS

Under acute and chronic conditions, Pebisut® strengthened and made the suture lines more resistant, while histologically penetrating and sealing them. The adhesive disappears within 2-3 weeks and is well tolerated by the intestinal tissues.

CONCLUSIONS

This biodegradable adhesive provides greater resistance, temporarily protects suture lines and may prevent anastomotic leaks.

Clinical results using bioabsorbable staple-line reinforcement for circular stapler in colorectal surgery: a multicenter study

INTRODUCTION

Anastomotic leakage is a serious postoperative complication of open and laparoscopic colorectal surgery, very often associated with higher morbidity and mortality. Despite proper patient selection and surgical technique, anastomotic leakage cannot be avoided. The use of a synthetic, bioabsorbable staple-line reinforcement material for the circular stapler may help reduce its prevalence.

METHODS

From May to December of 2006, 14 doctors, from 18 hospitals in the United States, performed 117 laparoscopic and open colorectal procedures, in which circular bioabsorbable Seamguard (CBSG; W.L. Gore and Associates, Elkton, MD) was used.

RESULTS

Eighty-three patients underwent laparoscopic surgery (70.0%) and 34 open surgery (30%). The procedures included low anterior resection in 49 patients (42%), sigmoidectomy in 46 patients (39.5%), left hemicolectomy in 12 patients (10%), and total colectomy in 10 patients (8.5%). Sixty-four patients had benign disease and 36% malignant disease. Intraoperative anastomotic leakage tests identified 4 patients with leakage (3.4%). All 4 patients had a very low anastomosis (1, 3, 4, and 6 cm, respectively, from the anal verge). Two of the leaks resolved without further intervention. A fecal diversion procedure was performed in the other 2 patients, including 1 patient with rectal bleeding, requiring a transfusion. No clinical complications related to use of CBSG were reported.

CONCLUSIONS

The use of Seamguard in colorectal open and laparoscopic surgery may result in a lower incidence of anastomotic leakage.

Comparison of hemostatic properties between collagen and synthetic buttress materials used in staple line reinforcement in a swine splenic hemorrhage model

INTRODUCTION

The use of staplers in gastrointestinal surgery is widespread, especially in advanced laparoscopic procedures. Staple line reinforcement with a buttress reduces bleeding and associated complications through a combination of factors. The intrinsic hemostatic properties of buttress materials have not been examined. This study examined the intrinsic hemostatic properties of two different types of material used in buttressing in an accepted hemostasis model that does not involve stapling or its effects by compression.

MATERIALS

An acellular collagen buttress (Veritas) and a synthetic polymer buttress (Duet) were compared to two commonly used hemostatic agents, Syvek and Surgicel, with gauze as control.

METHODS

In a swine capsular stripping hemostasis model, a 1 × 1 cm section of spleen capsule was removed and used as a source of bleeding, with one patch of material tested per bleeding site. A total of 51 wounds were created in five pigs (each patch n = 10, control n = 11). Hemostatic efficacy was assessed by quantitating the number of applications and total time needed for bleeding to stop.

RESULTS

The mean time needed for hemostasis for Syvek and Veritas patches was significantly less than gauze, Duet and Surgicel (4.02, 4.51 vs. 8.97, 9.22, and 10.30 min respectively; p < 0.05). The Syvek and Veritas patches required significantly fewer applications than gauze, Duet™ and Surgicel (1.7, 2.2 vs. 4.1, 4.6, and 4.9 respectively; p < 0.01).

CONCLUSIONS

The intrinsic hemostatic properties of different buttressing materials vary widely. In this study, a collagen buttress was significantly better at promoting hemostasis than the synthetic buttress material in a nonstapling model. This could be another factor to consider when choosing a buttress for staple line reinforcement.

T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature

Laparoscopic sleeve gastrectomy has recently become a feasible option in the management of morbid obesity. One of the most feared complications of this procedure is staple line disruption and leakage. There are, to our knowledge, few literature reports that try to explain the reasons and management of this rare but serious complication. We report a case of staple line disruption that was managed using a T-tube gastrostomy. A 50-year-old female, 2 weeks status post-sleeve gastrectomy in an outside facility, was admitted to the emergency room at Cleveland Clinic Florida with new onset of fever, abdominal pain, jaundice, hematemesis, and melena. A computed tomography scan of the abdomen revealed a large extravasation of contrast material parallel to the gastric sleeve. A diagnostic laparoscopy was performed that showed a distal and proximal disruption of the staple line. A T-tube gastrostomy with a large proximal and distal limb was placed into the most distal area of disruption. After thorough over sewing and drainage of the proximal site and T-tube, a feeding jejunostomy was placed. The T-tube permitted to control the leak and to have a controlled fistula. Four weeks postoperatively, the T-tube was removed after the patient had a negative Gastrografin study and tolerated oral fluids with a clamped T-tube. The long-term recovery and follow-up were uneventful. T-tube gastrostomy appears to be a safe and feasible treatment option for staple line disruption after vertical sleeve gastrectomy. Early detection and drainage remain the most important principles to manage this type of complication.

Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause.

METHODS

The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks.

RESULTS

Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41-3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures.

CONCLUSIONS

There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.

The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007

Sleeve gastrectomy is a rapid and less traumatic operation, which thus far is showing good resolution of comorbidities and good weight loss if a narrower channel is constructed than for the duodenal switch. There are potential intraoperative complications, which must be recognized and treated promptly. Like other bariatric operations, there are variations in the technique used. The laparoscopic sleeve gastrectomy (LSG) is being performed for super-obese and high-risk patients, but its indications have been increasing. A second-stage bariatric operation may be performed if necessary, with increased safety. Long-term results of LSG and further networking are anxiously awaited.