Reinforcing the staple line during laparoscopic sleeve gastrectomy: does it have advantages? A meta-analysis

Staple Line Reinforcement during Sleeve Gastrectomy with SeamGuard: Single-Center Retrospective Case-Control Study over a 5-Year Period

Introduction: Various techniques and reinforcements have been proposed over the years in order to prevent leaks and bleeding after sleeve gastrectomy (LSG). The aim of this study was to retrospectively compare the staple line complication (SLC) rate in patients who underwent LSG with the use of bioabsorbable membrane (GORE® SEAMGUARD®, GoR) for staple line versus those who received no reinforcement. Methods: Data on all consecutive patients undergoing LSG between 1 January 2014 and 31 December 2018 were retrospectively reviewed. Patients were divided into two groups: the GoR+ group if the SeamGuard (GoR) was used and the GoR- group if no reinforcement was applied on the staple line. Preoperative demographics and rate of SLC were compared between groups. All cases of SLC coming from other centers were also reviewed. Results: A total number of 626 LSGs were performed at our institution during the study period. GoR was applied in 450 (71.9%) cases (GoR+ group), while NR was used in 176 (28.1%) patients (GoR- group). Two (1.13%) cases of leaking and two (1.13%) cases of bleeding occurred in the GoR- group, while no SLC was recorded in patients who received GoR (p < 0.05). Thirteen cases of SLC coming from other institutions were treated at our hospital; all these cases were performed without any SLR. Conclusion: In our case series, the use of GoR reduced the rate of SLC after LSG. In all cases of SLC coming from other institutions, no reinforcement had been applied on the staple line during LSG.

Reinforcement in Laparoscopic Sleeve Gastrectomy: Is It Effective?

BACKGROUND

Despite the success of bariatric surgery in treating obesity, it can still lead to complications. The most serious and feared technical complications are bleeding and leakage from the gastric staple line. In this study, stapler line reinforcement was investigated to determine whether it affects postoperative leakage and bleeding rates and their management.

MATERIALS AND METHODS

Overall, 510 patients who underwent sleeve gastrectomy were evaluated retrospectively. They were divided into 2 groups according to whether reinforcement of the staple line with running imbricating sutures was performed.

RESULTS

In the reinforcement group, there were two leaks (0.7%), which were diagnosed seven and eight days after surgery. In the non-reinforcement group, there were nine leaks (4%). There was no difference between the two groups in staple line bleeding.

CONCLUSIONS

This study shows that reinforcement with continuous imbricating sutures is associated with less stapler line leakage and a lower reoperation rate at the cost of increased operative time.

Oversewing the Staple Line: Does It Safe to Prevent Leakage?

Introduction: The staple line (SL) leak remains one of the most serious complications after laparoscopic sleeve gastrectomy (LSG). The present study aims to determine whether reinforcing the SL with sutures is effective in maintaining tissue integrity. Materials and Methods: LSG Specimens of 60 patients were ex vivo studied. The specimens were divided into three groups: In group 1, the entire SL was reinforced, while the upper half part of the SL was reinforced from fundus to antrum in group 2. The SL was not reinforced in group 3. Then, the pressure inside the sample was increased, and the bursting pressure location and pressure value during the bursting were recorded. Results: The bursting pressure was significantly higher in entire and half oversewed SL groups than the none reinforced group (group 1: 115 mmHg [95-170]; group 2: 95 mmHg [80-120]; group 3: 40 mmHg [22-60], respectively, [P < .001]). The most common site of bursting was in the middle ⅓ of SL (35, 53.8%), followed by the proximal ⅓ part of SL (18, 27.7%), and the distal ⅓ part of SL (12, 18.5%), respectively. The bursting site was significantly more frequent in the corpus than the other parts of the SL (P = .013). Conclusion: Reinforcing the SL with sutures preserves tissue integrity. Although bursting was most frequently observed in the corpus region ex vivo, the fact that almost all real-life leaks develop in the area close to the Angle of His. This situation suggests that strengthening the suture line with reinforcement alone will not be protective enough against leaks in the fundus line, and factors such as tissue ischemia may be considered.

The Effects of Reinforcement Techniques in Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Protocol for a Web-Based Survey, Systematic Review, and Meta-Analysis

BACKGROUND

The effects of reinforcement are still controversial in bariatric surgery, and variations may exist in using this technique.

OBJECTIVE

This protocol describes a study that aims to survey the views of bariatric surgeons on reinforcement techniques and evaluate the effects of applying reinforcement techniques in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

METHODS

This study is composed of 2 parts. Part 1 will investigate the differences of using reinforcement techniques among surgeons worldwide who perform SG or RYGB through a survey. The survey will be conducted by email and social media. Part 2 will evaluate the safety and effectiveness of using omentopexy or staple line reinforcement in SG and RYGB by systematic review and meta-analysis. In this part, literature searches will be performed in English databases, including CENTRAL, EMBASE CINAHL, Web of Science, and PubMed, and Chinese databases, including Wanfang, China National Knowledge Infrastructure, Database of Chinese Technical Periodicals, and Chinese Biological Medicine, from their establishment to November 2023. Randomized controlled trials and case-control studies will be included. The primary outcomes are rates of postoperative bleeding and gastric leakage. The secondary outcomes include anastomotic stenosis, surgical site infection, reoperation, estimated intraoperative blood loss, operative time (minutes), length of hospital stay (days), overall complications, and 30-day mortality. The meta-analysis will be conducted using RevMan 5.4 under the random-effects model, as well as through extensive subgroup and sensitivity analyses. P values <0.05 will be considered statistically significant. This study was registered with PROSPERO (Prospective Register of Systematic Reviews) in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols).

RESULTS

The results of this study will be published in a peer-reviewed journal. The web-based survey and initial title or abstract review of papers identified by the search strategy will be completed in November 2023. The second round of title or abstract review and downloading of the papers for full-text inclusion will be completed in January 2024. We aim to complete data extraction and meta-analysis by February 2024 and expect to publish the findings by the end of March 2024.

CONCLUSIONS

This study aims to investigate the impact of reinforcement techniques on reducing the incidence of postoperative complications in SG and RYGB procedures and provide assistance for standardizing the procedures of SG and RYGB operations for bariatric surgeons.

TRIAL REGISTRATION

PROSPERO CRD42022376438; https://tinyurl.com/2d53uf8n.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50677.

A comparative study between staple line reinforcement during laparoscopic sleeve gastrectomy and no reinforcement: an Egyptian experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years.

PATIENTS AND METHODS

This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR.

RESULTS

The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289).

CONCLUSION

This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.

Outcomes of Staple Line Reinforcement Following Robotic Assisted Sleeve Gastrectomy Based on MBSAQIP Database

INTRODUCTION

The objective of this study is to evaluate the outcomes for Staple Line Reinforcement (SLR) in RA-SG based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for 2019.

MATERIALS AND METHODS

We selected patients who underwent RA-SG in the MBSAQIP PUF (Public Utility File) for the year 2019 and grouped them based on their SLR status: Oversewing (OS), Buttressing (BR), both OS and BR and neither. Our primary outcomes were bleeding, organ space infection (OSI), and adverse events (AEs), and our secondary outcomes were operation length, hospital length of stay, readmissions, and conversion to open rates. We conducted separate chi square or one-way analysis of variance (ANOVA) as appropriate and multivariable direct logistic regression models for the categorical outcomes.

RESULTS

We found 115,621 patients with complete data of which there were 16,494 who underwent RA-SG. Our results did not show a statistically significant decrease in incidence of postoperative bleeding for BR and OS (Adjusted OR = 0.782, p = 0.2291 and Adjusted OR of 0.482, p = 0.054 for BR and OS respectively). There was a statistically significant effect for SLR status on operation length, with OS patients having the highest operative times (log-transformed mean = 2.03), followed by both BR + OS patients (log-transformed mean = 1.99). BR patients had the shortest operation length.

CONCLUSION

SLR did not result in any significant differences related to bleeding, OSI or AEs following RA-SG according to MBSAQIP for the year 2019. However, OS resulted in significantly longer operative time compared to BR alone.

Oversewing/Suturing of the Staple Line During Sleeve Gastrectomy Is an Effective and Affordable Staple Line Reinforcement Method: a Meta-analysis of Randomized Controlled Trials

Bleeding and leaks are the most ominous postoperative complications after laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) techniques have been innovated such as oversewing/suturing (OS/S), omentopexy/gastropexy, buttressing, and gluing. Currently, no high-quality evidence supports the use of one method over the others or even supports the use of SLR over no SLR. This study aimed to compare postoperative outcomes between LSG with OS/S versus LSG without any SLR.

The clinical effectiveness of staple line reinforcement with different matrix used in surgery

Staplers are widely used in clinics; however, complications such as bleeding and leakage remain a challenge for surgeons. To tackle this issue, buttress materials are recommended to reinforce the staple line. This Review provides a systematic summary of the characteristics and applications of the buttress materials. First, the physical and chemical properties of synthetic polymer materials and extracellular matrix used for the buttress materials are introduced, as well as their pros and cons in clinical applications. Second, we review the clinical effects of reinforcement mesh in pneumonectomy, sleeve gastrectomy, pancreatectomy, and colorectal resection. Based on the analysis of numerous research data, we believe that buttress materials play a crucial role in increasing staple line strength and reducing the probability of complications, such as bleeding and leakage. However, considering the requirements of bioactivity, degradability, and biosafety, non-crosslinked small intestinal submucosa (SIS) matrix material is the preferred candidate. It has high research and application value, but further studies are required to confirm this. The aim of this Review is to provide comprehensive guidance on the selection of materials for staple line reinforcement.

Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis

BACKGROUND

Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing.

METHODS

MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors.

RESULTS

Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR.

CONCLUSIONS

Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.

Tranexamic acid effects in postoperative bleeding outcomes in laparoscopic sleeve gastrectomy: a controlled study

PURPOSE

To demonstrate through a controlled study whether the use of tranexamic acid in bariatric surgeries is effective for bleeding control.

METHODS

Prospective, comparative, and double-blind study performed with patients from 18 to 65 years old submitted to bariatric surgery. The selected patients received venous tranexamic acid (TXA) during the induction of anesthesia or not (CG). The anesthesia and thromboprophylaxis protocols were similar among the groups. For statistical analysis, the χ2 and analysis of variance tests were performed at a significance level of p < 0.05, using the statistical program SPSS 21.0®.

RESULTS

Sixty-one patients were included in the study, 31 in the control group and 30 in the TXA group (GTXA). In the intraoperative period, the bleeding volume was greater in the CG than in the GTXA. In the postoperative period, the tranexamic acid group had a higher value hematocrit, absence of surgical reoperations due to bleeding complications, and shorter hospitalization time than the control group.

CONCLUSIONS

The use of tranexamic acid was effective in reducing bleeding rates and of hospital stay length, in addition to demonstrating the clinical safety of its use, for not having been associated with any thromboembolic events.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database

BACKGROUND

Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database.

METHODS

The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days.

RESULTS

A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m². Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05).

CONCLUSIONS

Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study

Introduction: Staple-line bleeding and gastric leakage are the most serious complications of laparoscopic sleeve gastrectomy (LSG). Reinforcement of the staple line is reported to be a method to reduce these complications rates, but the question of which method is preferable is a matter of controversy in the literature. In this study, we compared different staple-line reinforcement methods to assess their efficiency in preventing staple-line bleeding and leakage. Materials and Methods: Two hundred patients eligible for LSG were enrolled in the study and randomized into five groups based on the reinforcement method used during surgery: no reinforcement, oversewing using 3-0 polydioxanone (PDS) suture, oversewing using 4-0 barbed absorbable closure device (V-Lock), fibrin sealant glue, and buttress material. Intraoperative and postoperative complications were recorded and analyzed. Differences were considered statistically significant for P < .05. Results: The no-reinforcement group showed higher bleeding rates (20%), although only 2.5% of the patients required reintervention. All groups using staple-line reinforcement showed better outcomes in bleeding rates (P < .05). No statistically significant differences were observed among the groups in terms of the leakage rate, reintervention rate, intraoperative complications, and operative times. Conclusion: The reinforcement of the staple line decreased the bleeding rate in sleeve gastrectomy but did not affect the gastric leakage rate.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Purpose

Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR.

Materials and Methods

Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures.

Results

Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality.

Conclusions

SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05950-z.

A reinforced suture method for stapled gastrointestinal anastomosis to reduce gastrointestinal hemorrhage during Whipple operation in laparoscopy

Purpose

Laparoscopy is being increasingly accepted for pancreaticoduodenectomy. Stapled anastomosis (SA) is used extensively to facilitate laparoscopic pancreaticoduodenectomy (LPD); however, the incidence of anastomotic bleeding after stapled gastrointestinal anastomosis is still high.

Methods

One hundred and thirty-nine patients who underwent LPD using Whipple method were enrolled in our study. We performed the SA with our reinforced method (n = 68, R method) and without the method (n = 71, NR method). We compared the clinical characteristics and anastomosis methods of patients with or without gastrointestinal-anastomotic hemorrhage (GAH), and operative parameters were also compared between the anastomotic methods.

Results

Of the 139 patients undergoing LPD, 15 of them developed GAH. The clinical characteristics of patients with or without GAH were not significantly different except in the anastomotic method (P < 0.001). In the univariate logistic regression analyses, only the anastomotic method was associated with GAH. Furthermore, patients with the NR method had significantly higher incidences of GAH (P < 0.001) and Clavien-Dindo grade ≥ III complications (P < 0.001).

Conclusion

Our retrospective analysis showed that the SA performed with reinforced method might be a reform of SA without the reinforcement, as indicated by the lower incidence of GAH. However, further research is necessary to evaluate the utility of this reinforced method.

Review of Our Experience Using Modified Staple Line Suturing Technique in Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgical method in recent years. Although LSG provides good outcomes, serious complications such as leakage, bleeding, and stenosis may develop postoperatively. Numerous staple line reinforcement methods have been used to reduce complications. Whether each one of these practices is effective remains controversial.

AIM

Our study aims to assess outcomes and safety of modified (purse-string+oversewing) staple line suturing technique for patients who underwent LSG.

MATERIALS AND METHODS

A total of 505 patients who underwent LSG with modified staple line suturing technique between March 2018 and February 2021 were included in this retrospective study. Age, sex, body mass index, operation time, perioperative and postoperative 30-day complications were recorded in all patients.

RESULTS

Of 505 patients (59.6% female) with a mean age of 37.6 years (minimum to maximum: 12 to 68 y) and median body mass index of 40.2 kg/m2 (minimum to maximum: 32 to 75 kg/m2) underwent LSG. LSG was performed as revision surgery in 17 (3.4%) patients. Five (1%) patients also underwent concomitant cholecystectomy. The mean operation time was 92 minutes (75 to 110 min) in our primary LSG cases. Operative complications included minor hepatic injury in 8 (1.6%) and anesthesia awareness in 3 (0.6%) patients. Postoperative complications included bleeding which occurred in 2 (0.4%) patients, portomesenteric vein thrombosis in 1 (0.2%), and minor wound infection in 3 (0.6%) patients. There was no leak, no stenosis, and no mortality.

CONCLUSION

Sleeve gastrectomy with modified staple line suturing technique is an effective method and could be safely applied with low morbidity.

Development of consensus-derived quality indicators for laparoscopic sleeve gastrectomy operative reports

BACKGROUND

Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved.

METHODS

A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators.

RESULTS

Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65.

CONCLUSION

This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Is Staple Line Reinforcement Necessary in Conversion From Laparoscopic Adjustable Band to Laparoscopic Sleeve Gastrectomy?

BACKGROUND

Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves.

METHODS

The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015-2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied.

RESULTS

Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups.

CONCLUSION

Choice of SLR does not affect number of bleeding events or staple line leak rate.

Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies

Purpose

Among various staple-line reinforcement methods applied during sleeve gastrectomy (SG), although data on full-thickness-continuous-suturing (FTCS) is nearly nil, it has been considered as potentially harmful. The safety/efficacy profile of FTCS is assessed.

Methods

All consecutive SGs completing 3-month follow-up were studied. Data on peri-operative parameters, complications, and follow-up were prospectively recorded. All reinforcements were completed by FTCS utilizing barbed suture. Super-super obese, secondary SGs, SGs performed in patients with prior anti-reflux surgery, and SGs performed with additional concomitant procedures were evaluated as “technically demanding” SGs. Student’s t/chi-square tests were used as appropriate.

Results

Between January 2012 and July 2020, 1008 SGs (941 “primary-standard,” 67 “technically demanding”) were performed without mortality/venous event. Single leak occurred in a patient with sleeve obstruction (0.1%). Thirteen bleedings, 4 requiring re-surgery (0.4%), and 17 stenoses (1.7%) were encountered. Four stenoses were treated with gastric bypass (1 emergency), 6 by dilatation(s), and one required parenteral nutrition. Six patients with stenosis chose not to have any treatment. No statistically significant difference was observed in postoperative complications between “primary-standard” and “technically demanding” SGs (p > 0.05). The median follow-up was 44 months. The excess weight loss % at 5th year was 80.1%. Suturing added 28.4 ± 6 minutes to the SG, 3 or fewer sutures were used to complete the reinforcement in > 95%. No mishap/complication occurred related to suturing.

Conclusion

FTCS produced excellent result in terms of leakage/hemorrhage with an acceptable stenosis rate at a low cost with half-an-hour increase in the operating time. In contrast to previous allegations, no harm attributable to stitching itself occurred.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02161-5.

Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures

BACKGROUND

Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG.

METHODS

A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics.

RESULTS

Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively.

CONCLUSION

There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.

To oversew or not to oversew in robotic sleeve gastrectomy: a case against oversewing the staple line

BACKGROUND

The benefits of oversewing the staple lines during laparoscopic sleeve gastrectomy have been controversial. No study examined the benefit of oversewing the staple lines in robotic sleeve gastrectomy (RSG). This retrospective study aims to examine the difference in immediate postoperative complications, readmissions, reoperations, and emergency room visits between RSG patients with and without oversewn staple lines at a single, large-volume, bariatric center.

METHODS

A retrospective chart review was conducted on 623 patients who underwent RSG between November 1, 2017, and November 1, 2019. Of these, 316 had their staple line oversewn between November 1, 2017, and November 12, 2018, and 307 did not have their staple line oversewn between November 13, 2018, and November 1, 2019.

RESULTS

A total of 623 patients underwent RSG, of which 50.7% (n = 316) had their staple line oversewn. The mean length of hospital stay was similar between the two groups. However, the mean operative time was significantly longer in the "oversew" group than "no oversew" group by 7.4 minutes (p < 0.001). Readmission, reoperation, and intervention rates during the 30-day postoperative period were similar between the two groups. However, the percentage of patients requiring outpatient emergency room visits during the 30 days after RSG was significantly higher in the "oversew" group than that of the "no oversew" group.

CONCLUSIONS

No significant difference in major complications was found between RSG patients with and without oversewn staple lines. Oversewing of the staple line may be associated with increased emergency room visits.

Laparoscopic Sleeve Gastrectomy with Omentopexy: Is It Really a Promising Method?-A Systematic Review with Meta-analysis

Purpose

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedure worldwide. Omentopexy during LSG is a novel variation of this well-established technique. There are no clear conclusions on indications for this procedure, safeness, and effects of such a method. We aimed to compare the outcomes of laparoscopic sleeve gastrectomy (LSG) with omentopexy (OP) and without omentopexy.

Materials and Methods

We searched the Medline, EMBASE, and Scopus databases up-to June 2020. Full-text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

Results

Of initial 66 records, only 4 studies (N = 1396 patients) were included in the meta-analysis. Our findings showed that LSG with omentopexy had significantly lowered overall morbidity compared to LSG without omentopexy (RR = 0.38; 95% CI [0.15, 0.94]; p=0.04). Gastric leakage rate (RR = 0.17; 95% CI [0.04, 0.76]; p = 0.02) was also significantly lower in LSG with omentopexy. There were no significant differences between groups in length of hospital stay.

Conclusions

Our meta-analysis showed that LSG with omentopexy may be a feasible procedure for decreasing morbidity and gastric leak rate. However, despite promising results, the procedure needs to be researched more in randomized controlled studies to draw solid conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05327-8.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

The Impact of the Gastric Twist on Esophagitis Progression After Sleeve Gastrectomy: Mid-Term Endoscopic Findings

PURPOSE

To determine the real influence of the gastric twist on the progression of esophagitis after SG, evaluating pre- and late post-operative endoscopic findings.

MATERIAL AND METHODS

We retrospectively included 459 patients submitted to SG between 2009 and 2019. The sample comprised patients who performed esophagogastroduodenoscopy (EGD) at the pre-operative and late post-operative periods.

RESULTS

Patients were mainly female (85.6%), with a mean age of 40.4 years. Mean follow-up time was 20.8 months. In the pre-operative period, 1.1% of patients had non-erosive esophagitis, 24.2% of patients had grade A erosive esophagitis, and 1.5% of patients had grade B. In the post-operative evaluation, 3.3% had non-erosive esophagitis, 14.8% presented grade A erosive esophagitis, 8.9% had grade B, and 1.3% had grade C esophagitis. There were no cases of Barrett's esophagus. Forty-nine patients (10.7%) presented gastric twist. Comparing patients with and without gastric twist, it was possible to observe that the gastric twist group presented a higher incidence of grade C esophagitis (4.0% × 1.0%), p = 0.017. The correlation between the occurrence of gastric twist and esophagitis progression showed a prevalence ratio of 1.36 (95% CI 0.82-2.25).

CONCLUSIONS

SG is responsible for an increase in the prevalence of erosive esophagitis, and the occurrence of gastric twist definitely plays a role on it, expressing a risk of 36% for esophagitis progression and being related to a higher incidence of severe esophagitis.

Does Fixation of Gastric Sleeve Prevent Functional Stenosis in Sleeve Gastrectomy Patients?

AIM

The aim of this study is to determine whether gastric sleeve fixation prevents functional stenosis (twist or kink) and to investigate its effects on symptoms such as nausea and vomiting after laparoscopic sleeve gastrectomy (LSG).

METHODS

A total of 717 patients who underwent primary LSG for morbid obesity and completed at least 1 year of follow-up between 2012 and 2019 were included in the study. All operations were performed by the same surgical team using the same technique. The patients were divided into 2 groups, that is, group 1: standard LSG and group 2: gastric sleeve fixation with LSG. These 2 groups were compared in terms of demographic characteristics, baseline body mass index, follow-up duration, bleeding, leaks, gastric stenosis, postoperative nausea, vomiting, and the need for antiemetics. In the follow-up period, patients with suspected gastric stenosis underwent endoscopy and upper gastrointestinal series.

RESULTS

LSG was performed in 717 patients (55.2% female) with a mean age of 37.8±11.5 years and a median body mass index of 42.2 (30.2 to 74.2) kg/m2. The 241 patients in the first group underwent LSG without fixation, and the 476 patients in the second group with fixation. Functional stenosis was detected in 8 patients, all of whom were in group 1. One patient in group 1 had a leak on the background of functional stenosis. There was bleeding that required transfusion in 2 patients (group 1) and reoperation in 2 patients (group 2). None of the study patients died. During the in-hospital period, 122 (50.6%) patients in group 1 and 159 (33.4%) patients in group 2 had nausea and vomiting that required antiemetic treatment (P<0.001).

CONCLUSION

Gastric sleeve fixation in LSG prevents complications that may arise because of improper gastric mobilization. This method is effective in reducing nausea and vomiting in LSG patients.

Surgical Outcomes, Health Care Utilization, and Costs Associated with Staple Line Buttressing Among Primary Sleeve Gastrectomy Patients

Purpose

Staple line buttressing is a method of reinforcing surgical staple lines using buttress materials. This study evaluated surgical outcomes, hospital utilization, and hospital costs associated with staple line buttressing among patients who underwent primary laparoscopic sleeve gastrectomy (PLSG) in the United States.

Methods

This was a retrospective cohort study using Premier Healthcare Database data from January 1, 2012 to December 31, 2017. Patients aged ≥ 18 years who underwent PLSG were selected and assigned to buttress or non-buttress cohorts based on the use of buttress material during their hospitalization for PLSG (index). Propensity score matching (PSM) was conducted to balance patient demographic and clinical characteristics between the cohorts. Generalized estimating equation models were used to compare the clinical and economic outcomes of the matched buttress and non-buttress users during the index hospitalization.

Results

A total of 38,231 buttress and 27,349 non-buttress patients were included in the study. After PSM, 24,049 patients were retained in each cohort. Compared with non-buttress cohort, the buttress cohort patients had a similar rate of in-hospital leaks (0.28% vs 0.39%; p = 0.160) and a lower rate of bleeding (1.37% vs 1.80%, p = 0.015), transfusion (0.56% vs 0.77%, p = 0.050), and composite bleeding/transfusion (1.57% vs 2.04%, p = 0.019). Total costs ($12,201 vs $10,986, p < 0.001) and supply costs ($5366 vs $4320, p < 0.001) were higher in the buttress cohort compared with the non-buttress cohort.

Conclusions

Staple line buttressing was associated with an improvement in complication rates for bleeding and transfusion. Total and supply costs were higher in the buttress cohort, necessitating further research into cost-effective buttressing materials.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04917-2) contains supplementary material, which is available to authorized users.

Trends and Outcomes of Laparoscopic Sleeve Gastrectomy Between 2015 and 2018 in the USA and Canada

BACKGROUND

Given there are approximately 100,000 primary laparoscopic sleeve gastrectomy (LSG) procedures performed a year in North America, there is a need to evaluate recent trends in LSG. The objective of this study was to analyze the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to identify trends in technical factors and patient outcomes over time.

METHODS

The MBSAQIP prospectively collects data from 854 centers in the USA and Canada. Patients undergoing primary LSG were included. Statistical analysis was performed to characterize trends in patient factors, technical factors, and 30-day postoperative outcomes.

RESULTS

A total of 434,030 patients underwent primary LSG. The mean age was 44.2 (SD 12.0) years and mean body mass index was 45.1 (SD 7.8) kg/m². Baseline demographics did not vary appreciably by year. Operative time decreased from 2015 to 2018 (75.4 to 70.6 min, p < 0.001). Bougie size and stapling distance from the pylorus did not change by year. However, staple line reinforcement (66.8 to 63.2%, p < 0.001) and oversewing of the staple line (23.1 to 20.1%, p < 0.001) were less commonly performed. Postoperatively, from 2015 to 2018, there was a 45.8% relative reduction in leaks (0.48 to 0.26%, p < 0.001). There were also reductions in 30-day major complications (2.87 to 2.28%, p < 0.001), length of stay (1.72 to 1.44 days, p < 0.001), and readmissions (3.39 to 2.77%, p < 0.001).

CONCLUSIONS

From 2015 to 2018, there was a decrease in staple line reinforcement and oversewing. These changes correlated with reductions in operative time, length of stay, readmission, and major complications.

Management of the staple line in laparoscopic sleeve gastrectomy: comparison of three different reinforcement techniques

BACKGROUND

Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line.

PATIENTS AND METHODS

A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed.

RESULTS

All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005).

CONCLUSION

The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Is There Necessity for Oversewing the Staple Line During Laparoscopic Sleeve Gastrectomy? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Laparoscopic sleeve gastrectomy (LSG) has become the current mainstream surgical treatment for obesity. With the development of clinical practice, surgeons realized the associated severity and danger of postoperative bleeding and leakage. Surgeons constantly explore different strategies to reduce the incidence of these complications. By reviewing previous clinical articles on the staple line reinforcement (SLR) in LSG, the conclusions were inconsistent regarding effectiveness. This article aims to discuss effectiveness of oversewing the staple line in LSG. Methods: From the start date of each database to September 27, 2018, a comprehensive search of published articles in English was conducted in PubMed, Embase, Central (Cochrane) databases and Scopus databases. We extracted and analyzed the main results on postoperative bleeding, staple line leakage, hospital stay and operative time of the final included articles. This review was compliant with PRISMA guidelines. Results: Finally, we extracted and analyzed 11 randomized controlled trials (RCTs) which contain 2411 patients (1219 patients as part of the oversewing (OS) group and 1192 patients in the no-oversewing (NOS) group). In the OS group, there were 15 cases (1.23%) of postoperative bleeding, and 8 cases (0.66%) of postoperative leakage. While in the NOS group, 35 patients (2.94%) had postoperative bleeding and 21 patients (1.76%) had postoperative leakage. By comparing and analyzing the OS group and the NOS group, the risk ratio (RR) for postoperative bleeding was 0.48 (95% confidence interval [CI], 0.27-0.83 p = 0.447). In addition, the RR for postoperative leakage was 0.44 (95% CI, 0.21-0.89 p = 0.835). The standardized mean difference (SMD) for hospital stay was -0.10 (95% CI, -0.25 to 0.04 p = 0.061) and 2.26 for operative time (95%CI, 0.82-3.69 p = 0.000). Conclusion: This study suggested that oversewing the staple line during LSG has a significant clinical value: it decreased the incidence of postoperative bleeding, postoperative leakage; moreover, it also significantly prolonged the operative time and but did not change hospital stay. More high-quality and large sample RCTs are expected to get more accurate results.

The potential effects of Ankaferd blood stopper and fibrin sealent on sleeve gastrectomy staple-line healing: An experimental study

Staple-line bleeding and leakage is a life-threatening complication in obese patients following laparoscopic sleeve gastrectomy. The aim of this study was to examine the potential effects of Ankaferd blood stopper (ABS) and Fibrin Sealant (FS; Tisseel^®) on sleeve gastrectomy staple-line healing in an experimental animal model. A total of 30 Wistar albino female rats were divided into three groups and were subjected to sleeve gastrectomy with linear stapling. Group A (control group) had nothing administered, Group B was administered FS on the staple-line, and Group C was administered ABS on the staple-line following sleeve gastrectomy. After sacrifice on postoperative day 5, anastomotic burst pressure, tissue hydroxyproline levels and histopathological parameters were measured. The results revealed that group C had the highest mean bursting pressure level. However, the values of this parameter were not found to differ significantly between the groups (P>0.05). Group B and C had a similar hydroxyproline levels but increased compared with group A (P<0.001). Histopathological parameters were similar between the groups, except macrophage scores in group C. In the present experimental study, ABS was demonstrated to improve gastric-sleeved staple-line healing compared with FS. ABS may be used as a novel reinforcement agent in bariatric surgery.

Long-term outcomes of laparoscopic sleeve gastrectomy - a single-center prospective observational study

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is an established bariatric procedure.

AIM

We present our long-term results regarding weight loss and comorbidities during 9 years.

MATERIAL AND METHODS

We calculated the percent excess weight loss (%EWL) and changes in body mass index (ΔBMI). We evaluated arterial hypertension (AHT), type 2 diabetes (T2DM) and obstructive sleep apnea syndrome (OSAS).

RESULTS

One hundred seventy-nine patients were included (136 female/43 male), mean age of 40.47 ±11.08 years, median preoperative body mass index (BMI) of 42.93 kg/m2. Median follow-up period was 72 months (36-84 months). The %EWL during follow-up was 41.8 (n = 179 patients, at 3-month follow-up), 64.1 (n = 163), 75.33 (n = 134), 77.1 (n = 103), 76,03 (n = 99), 73.78 (n = 64), 71.58 (n = 37), 63.83 (n = 22) and 64.1 (n = 14) at 6, 12, 18, 24, 36, 48, 60 and 72 months, respectively. We noted a negative correlation between %EWL and both the age and initial weight and BMI of the patient; a negative correlation between gender (male patients) and %EWL was also found. After LSG, 68.2% of patients with AHT presented resolution (no medication) or significant improvement (doses reduced) of the disease. As regards T2DM, 65.8% described resolution or significant improvement after surgery. Furthermore, 31 (70.4%) patients with preoperative OSAS reported resolution/improvement within a year from surgery.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is a safe and effective procedure, with good results in the short and medium term. Long-term follow-up reveals a tendency to weight regain after approximately 2 years from primary surgery, with the need for revisional surgery in some cases.

Standardised Sleeve Gastrectomy Without Reinforcement

Background and Objectives:

Laparoscopic sleeve gastrectomy (LSG) has some unique complications, the most concerning of which is sleeve leak. Staple line reinforcement (SLR) has been suggested as a means of decreasing the risk of sleeve leak, but it increases the cost. However, there is little in the literature regarding the effect of standardized operative technique in reducing the complications and improving the outcomes in LSG. We sought to demonstrate that standardization of the operative procedure and perioperative care is the key to an excellent 30-day outcome and that SLR is not necessary to ensure a negligible staple line leak and bleeding rate.

Methods:

A prospectively maintained database was analyzed to identify 303 consecutive patients undergoing LSG between July 2010 and November 2017. Data on patient demographics, length of hospital stay, conversion to open surgery, perioperative complications, and mortality were analyzed. Standardized operative technique and postoperative protocol were followed in all cases. SLR was not used in any case.

Results:

Among 303 cases, there were 15 complications (5%), 5 (1.7%) of which were severe (Clavien-Dindo grade ≥3a). There were no conversions to open procedure, no staple line leaks, and no inpatient deaths in the cohort. No patient was readmitted with an early stricture.

Conclusions:

The use of a standardized operative and postoperative protocol led to an excellent early outcome in our LSG cases. Standardization may act to obviate the need for routine SLR techniques which are associated with a significant financial cost to both patient and hospital.

Stapleless Laparoscopic Sleeve Gastrectomy: Reasoning and Technical Insights

Background

Laparoscopic sleeve gastrectomy (LSG) with staple line reinforcement (SLR) is a popular and safe treatment option for morbid obesity. We have developed, devised, and described our own method of stapleless laparoscopic sleeve gastrectomy, which in our limited study appeared safe, efficacious, and potentially cost-effective.

Methods

We analyzed the outcome of our modified LSG in a case series of three middle-aged women (median age 42 years old). Our main modification was sutured closure of the stomach rather than the commonly utilized technique of stapled closure. Our primary measure of success was the occurrence of post-operative leak. Secondary measures were (a) length of operation, (b) duration of inpatient stay, and (c) percentage of weight loss at 6 and 12 months post operation.

Results

Median operative time = 132 min (120–195 min), and median inpatient stays were 2 days. No post-operative leaks were recorded. The median excess weight loss at 6 months was 39% of initial weight loss and 57.7% at 12 months.

Conclusions

Stapleless LSG has the potential to be an affordable alternative to the traditional LSG. High-powered studies and a formal cost analysis are required.

Effects and Results of Omentopexy During Laparoscopic Sleeve Gastrectomy

PURPOSE

The aim of this study was to demonstrate that gastric volvulus can be prevented by omentopexy and sleeve gastrectomy without increasing other complication rates.

MATERIALS AND METHODS

A total of 1385 patients who underwent omentopexy and sleeve gastrectomy between April 2013 and September 2017 were included this study. Body mass index, age, sex, comorbidities, and postoperative complications of the patients were recorded as data.

RESULTS

A total of 1385 patients underwent sleeve gastrectomy and omentopexy. There were 999 female and 386 male patients. The mean age of the patients was 36 years (14 to 71 y). The mean body mass index was 42.74 kg/m (35 to 73 kg/m). Twenty-one patients had previously undergone gastric banding and the other 80 patients had previous abdominal operation. The number of patients undergoing simultaneous cholecystectomy was 98. Three patients had hemorrhage due to hypertension and anticoagulant treatment in the postoperative period and the patients were treated medically. One staple-line leakage was observed. Twist, and stricture were not observed and no mortalities were noted.

CONCLUSIONS

Sleeve gastrectomy and omentopexy can prevent the gastric twist, which is a functional cause of gastric stenosis, by stabilizing the posterior stomach wall.

Complications after laparoscopic sleeve gastrectomy: can we approach a 0% rate using the largest staple height with reinforcement all along the staple line? Short-term results and technical considerations

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe the results of a single center's experience with SG, revealing a low complication rate.

OBJECTIVES

The aim of the study was to analyze the short-term results of laparoscopic SG using exclusively black staples with staple-line reinforcement.

SETTINGS

University hospital, tertiary referral center for bariatric surgery.

METHODS

SG was performed in 434 consecutive patients from December 2014 to March 2017. A technique is described where all operations were performed with attention to avoiding strictures at the incisura angularis and not stapling near the esophagus at the angle of His. All the interventions were performed using black cartridges and staple-line reinforcement using bioabsorbable Seamguard. A prospective chart review was conducted to determine the occurrence of early complications.

RESULTS

Follow-up data were collected for all patients at 90 days postoperatively. A total complication rate of 4.4% was observed. No leaks occurred in any of the patients. One case of bleeding occurred that necessitated a surgical exploration, which found the origin of the bleeding to be a diaphragmatic vessel. The 90-day mortality rate was 0%.

CONCLUSION

SG can be performed with a low complication rate. Selection of the appropriate staple height and reinforcement of the staple line could play a major role in optimizing the results of SG.

The Effect of the Cartridge Used in Laparoscopic Sleeve Gastrectomy on the Development of a Staple-Line Leak

Morbid obesity surgery has increased by 450 per cent in the past decade. Preferred surgical techniques have also changed, and since 2014, the most common surgical procedure worldwide has been laparoscopic sleeve gastrectomy (LSG). The most serious complication of this surgery is staple-line leaks, which leads to significant increases in cost and a considerable rate of mortality. This study aimed to investigate the effects of staples used in LSG on the development of staple-line leaks. The sample of the study comprised 70 patients that consecutively underwent surgery at Dokuz Eylül University Hospital between March 2014 and June 2015. The patients were divided into two equal groups. For the first group, resection was performed using blue-green EndoGIA™ cartridges (BGC) (Medtronic, Norwalk, CT). In the other group, purple Tri-Staple™ cartridges (TSC) (Medtronic) were used. To examine the effect of the cartridge type, the point and pressure of leak was determined from fresh specimens following saline infusion. No statistically significant difference was found between the two groups in terms of mean age, body mass index, gender distribution or comorbidity. The median number of cartridges used was five in both groups. The resistance of the staple line to intragastric pressure was found to be significantly higher in the TSC group compared with the BGC group [51.94 (618.34) mmHg and 39.77 (617.09) mmHg, respectively, P = 0.005]. Most applications undertaken to reduce the risk of leak development in LSG aim to reinforce the staple line. There are very few studies that investigated the quality of staple line, and none examined the effect of staple cartridges on the development of leaks. Therefore, we conducted this study to fill this gap in the literature. The results revealed that tissue thickness cartridge compatibility had a role in the development of leaks during the resection of gastric tissue in which the thickness is reduced from the distal to the proximal portion. We conclude that during vertical sleeve gastrectomy, using TSC that are compatible with a wider range of tissue thickness results in more durable staple lines than EndoGIA™ cartridges.

Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015-2016 PUF

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity.

OBJECTIVE

To investigate the relationship between various SLR techniques and bougie size with 30-day outcomes.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery hospitals.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 Participant Use File data, primary LSG cases were divided into study groups based on surgical techniques. All variables were reported in the Participant Use File except leak rate and overall morbidity, which had to be derived. Multiple bivariate analyses were used to analyze the 30-day outcomes.

RESULTS

A total of 198,339 primary LSG operations were included and grouped into No SLR (23.0%), SLR (54.2%), oversewn staple line (9.5%), and a combination of SLR + oversewn staple line (13.3%). There were no statistical differences between study groups in mortality, overall morbidity, or leak rate. Bleeding and reoperation rates were statistically higher in the No SLR group. Bougie size was not associated with change in leak rates.

CONCLUSION

Primary LSG is a safe procedure with low morbidity and mortality rates. SLR is associated with decreased rates of bleeding and reoperations but does not affect leak rates. The selection of SLR technique should be left to the surgeon's discretion with an understanding of the associated risks, benefits, and costs.

Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center.

MATERIALS AND METHODS

We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR).

RESULTS

In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m²). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred.

CONCLUSIONS

LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.

Postoperative Bleeding and Leakage After Sleeve Gastrectomy: a Single-Center Experience

BACKGROUND

Sleeve gastrectomy is being performed increasingly, mainly due to its low morbidity and mortality, but complications do occur. The aim of this study was to evaluate bleeding and leakage rates of primary and revisional sleeve gastrectomy in a personal series of 664 consecutive patients.

METHODS

Medical charts of all patients undergoing a primary or revisional sleeve gastrectomy between August 2008 and December 2014 were reviewed retrospectively. Subgroup analysis compared bleeding in patients after reduced port versus multiport technique and primary versus revisional sleeve gastrectomy.

RESULTS

A total of 664 sleeve gastrectomies (489 women and 175 men) were performed. Mean age and body mass index were 36.03 ± 11.4 years and 42.9 ± 8.3 kg/m², respectively. Mean operative time was 58.5 ± 20.0 min, with a 0.15 % conversion rate. Mean hospital stay was 2.1 ± 0.3 days. The overall 30-day complication rate was 7.5 %. Thirteen patients sustained postoperative bleeding (2 %), three of whom required reoperation (0.5 %). Staple line leakage and mortality were both nil in this series. No difference in postoperative complications was found between the subgroups.

CONCLUSIONS

In this single-surgeon, single-center experience, sleeve gastrectomy was a safe and effective bariatric procedure with a low complication rate. Staple line reinforcement by oversewing was associated with low bleeding complications and no leakage. The majority of patients with postoperative bleeding could be managed conservatively. In our experience, reduced port technique and revisional sleeve gastrectomy had similar complication rates compared to multiport and primary sleeve gastrectomy.

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study

BACKGROUND

Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety.

METHODS

A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death.

RESULTS

The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02).

CONCLUSIONS

The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).

Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications

The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.

Staple line oversewing during laparoscopic sleeve gastrectomy

Introduction This meta-analysis was performed to assess the possible benefits of staple line oversewing during laparoscopic sleeve gastrectomy. Methods A comprehensive search up to February 2017 was conducted on PubMed, the Web of Science™ and Embase™. All eligible studies were included, and the outcomes of staple line bleeding and leak, overall complications and operative time were pooled. Results A total of 7 randomised controlled trials involving 845 patients (428 cases and 417 controls) were analysed. There was no significant difference in staple line bleeding (relative risk [RR]: 0.858, 95% confidence interval [CI]: 0.343-2.143, p=0.742), leak (RR: 0.650, 95% CI: 0.257-1.644, p=0.363) or overall complications (RR: 0.913, 95% CI: 0.621-1.342, p=0.644) between the oversewing group and the patients who did not have oversewing. Oversewing of the staple line was associated with a longer operative time (weighted mean difference: 14.400, 95% CI: 7.198-21.602, p=0.000). Conclusions Oversewing the staple line during laparoscopic sleeve gastrectomy does not decrease the risk of staple line bleeding, leakage or overall complications but it does prolong the operative time.

A Preventive Strategy for Staple Line Bleeding in Morbidly Obese Patients Undergoing Sleeve Gastrectomy

BACKGROUND

Risk factors for staple line bleeding (SLB) during and after sleeve gastrectomy (SG) are various, including patient related factors, perioperative medications, and surgical technique, although there is little clarification in the literature of the role played by blood pressure during the stapling phase. The aim of the present retrospective cohort study was to identify possible risk factors liable to cause SLB.

MATERIALS AND METHODS

Data collected prospectively from 120 consecutive patients who underwent SG were analyzed retrospectively according to age, gender, body mass index (BMI), international normalized ratio (INR) value, intraoperative systolic blood pressure (SBP), and mean arterial blood pressure (MABP).

RESULTS

In univariate analysis, age, stapling phase SBP and MABP, and the duration of surgery were all significantly higher in patients with SLB than those without (P < .05). In distinguishing patients with SLB from those without, the cutoff threshold for SBP during the stapling phase was 120 mmHg with a 78.9% sensitivity, 97.6% specificity, 93.8% positive predictive value, 90.9% negative predictive value, and 91.7% accuracy (AUC = 0.908, 95% CI: 0.839-0.976, and P < .001). In multivariate logistic regression analysis, independent of age and operation time, SBP >120 mmHg significantly maintained its predictive power on SLB (95% CI: 32.410-1457.896, P < .001).

CONCLUSION

A SBP >120 mmHg during the division of the stomach is an independent risk factor for SLB. Maintaining intraoperative SBP ≤120 mmHg during the stapling phase does not only decrease the risk of SLB but also the need for homeostatic agents such as clips and sutures, which in turn prolong the operative time and increase cost.

The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)

OBJECTIVE

Questions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year.

METHODS

Using the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level.

RESULTS

A total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00-1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63-0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62-0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80-0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP.

CONCLUSION

LSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.