A multicenter study of routine versus selective intraoperative leak testing for sleeve gastrectomy

Comparison of the postoperative outcome with and without intraoperative leak testing for sleeve gastrectomy: a systematic review and meta-analysis of 469 588 cases

OBJECTIVE

Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG.

METHODS

The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates.

RESULTS

Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05).

CONCLUSION

IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.

A Novel Intraoperative Leak Test Procedure (GAM Procedure) to Prevent Postoperative Anastomotic Leakage in Gastric Cancer Patients Who Underwent Gastrectomy

BACKGROUND

Anastomotic leakage following a radical gastrectomy is a serious complication of gastric cancer and esophagogastric junction cancer. The benefit of intraoperative leak testing for the prevention of postoperative anastomotic leakage has been controversial. We introduce a new procedure, which combines the techniques of gastroscopy, air, and methylene blue (GAM) for intraoperative leakage testing. Our objective was to evaluate the efficacy and safety of the GAM procedure for intraoperative leak testing and to compare the surgical complications of gastric cancer patients who underwent gastrectomy with and without intraoperative leak testing using the GAM procedure.

MATERIALS AND METHODS

A total of 210 patients who underwent radical gastrectomy for gastric cancer were included. Patients were divided into 2 groups: the intraoperative leak testing group using the GAM procedure (IOLT), and the group for which no intraoperative leak testing was done (NIOLT). Clinical and pathologic characteristics, the incidence of postoperative anastomotic leakage, and other surgical complications were compared between the 2 groups.

RESULTS

There were 82 patients in the IOLT group and 82 patients in the NIOLT group after propensity score matching. In the IOLT group, 4 (4.9%) patients were found to have anastomotic discontinuity during the operation; we repaired these anastomotic discontinuities intraoperatively. The incidence of postoperative anastomotic leakage was higher in the NIOLT group compared with the IOLT group, 6 (7.3%) versus 0 (0%), respectively ( P =0.01). The average time of the GAM procedure was 4.99±1.75 minutes. The surgical time was prolonged by 30 minutes in the IOLT group compared with the NIOLT group, 302.2±79.9 versus 272.1±85.2, respectively ( P =0.02). The length of hospital stay, 15.80±4.55 versus 17.00±6.20 ( P =0.16) was reduced in the IOLT group compared with the NIOLT group. The logistic regression model suggested that IOLT, sex, age, Eastern Cooperative Oncology Group, cT stage, tumor diameter, pT stage, pN stage, and Lauren classification were not risk factors for postoperative complication.

CONCLUSIONS

The GAM procedure of intraoperative leakage testing can effectively reduce the incidence of postoperative anastomotic leakage in gastric cancer patients undergoing gastrectomy.

Efficacy of air leak test in detection of anastomotic leaks after rectal excision: a retrospective case-controlled study

Purpose

Although its efficacy is uncertain, an intraoperative air leak test (ALT) is commonly used to detect mechanical defects following bowel anastomosis. This study aimed to evaluate the efficacy of ALT to detect anastomotic leakage (AL) following rectal excision.

Methods

We reviewed our database for patients with rectal cancers who had undergone curative surgery between January 2012 and January 2018. Patients were grouped according to whether or not an ALT was performed. Propensity score analyses were performed to compare outcomes for groups in a 1:1 case-matched cohort.

Results

In total, 1,191 patients underwent rectal excision; 438 (219 in each group) formed the case-matched cohort for analysis. The protective stoma rate was 16.0% and 14.6% in the ALT and the no-ALT groups, respectively (P = 0.791). In the ALT group, 2 patients (0.9%) showed a positive result and were treated with rectal tube drainage, resulting in no leakage. There was no significant difference in postoperative AL rate between the groups (ALT group: 4.6% vs. no-ALT group: 4.1%, P > 0.999).

Conclusion

ALT played a minimal role in detecting AL following rectal excision. Further studies are warranted to validate our results and clarify whether AL can be prevented with ALT or alternative methods.

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.

Intraoperative leak test is associated with lower postoperative bleed rate in primary sleeve gastrectomy: a propensity matched analysis of primary and revision bariatric surgery using the MBSAQIP database

BACKGROUND

Gastrointestinal leaks after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) occur infrequently but lead to clinical and socioeconomic burden on patients. Surgeons perform intraoperative leak test (IOLT) via gastric tube or endoscopy to help prevent postoperative leaks. However, there is knowledge gap in the literature on effectiveness of IOLT during bariatric surgery.

METHODS

In this observational cohort study using the 2015-2017 MBSAQIP database, we compared the outcomes in patients who received IOLT with those who did not during primary or revision RYGB and SG. The primary outcome was 30-day postoperative leak. Secondary outcomes were procedure duration and the rates of 30-day postoperative bleed, readmission, reoperation and intervention. Propensity score matching was used to assemble cohorts of patients with similar baseline characteristics.

RESULTS

Among 363,042 patients, 82% underwent IOLT. Four subgroups of patients who underwent operations with or without IOLT during primary RYGB (n = 13,756), primary SG (n = 110,810), revision RYGB (n = 1140), and revision SG (n = 5576) had similar propensity scores and were matched 1:1. Patients who underwent IOLT had similar postoperative leak rates compared to those who did not (Primary RYGB with IOLT 0.7% v. without IOLT 0.6%; Primary SG 0.4% v. 0.3%; Revision RYGB 2.3% v. 1.0%; Revision SG 1.1% v. 0.7%). In primary SG subgroup, patients who underwent IOLT had lower postoperative bleed rates (0.6% v. 0.8%, p = 0.002). In primary RYGB and SG subgroups, operations with IOLT were slightly longer.

CONCLUSION

Postoperative leak rates after primary and revision bariatric surgery were low and similar irrespective of IOLT. Patients who had IOLT during primary SG had lower postoperative bleed rates. Current judgment as to whether to perform an IOLT leads to excellent outcomes, and thus, current practices should continue. However, one should consider an IOLT during primary SG, not necessarily to reduce leak rates but to help reduce postoperative bleeding occurrences.

Endoscopy Used as Provocative Testing in Bariatric Surgery: An Analysis of the Texas Public Use Data File

Background

Many bariatric surgeons test the anastomosis and staple lines with some sort of provocative test. This can take the form of an air leak test with a nasogastric tube with methylene blue dye or with an endoscopy. The State Department of Health Statistics in Texas tracks outcomes using the Texas Public Use Data File (PUDF).

Methods

We queried the Texas Inpatient and Outpatient PUDFs for 2013 to 2017 to examine the number of bariatric surgeries with endoscopy performed at the same time. We used the International Classification of Diseases Clinical Modification Version 9 (ICD-9-CM) and ICD-10 procedure codes and Current Procedural Terminology for Sleeve Gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) and endoscopy, and the ICD-9-CM and ICD-10 diagnosis codes for morbid obesity.

Results

There were 74,075 SG reported in the Texas Inpatient and Outpatient PUDF for the years 2013-2017. Of the SG performed, 5,521 (7.4%) had an intraoperative endoscopy. For the 19,192 LRYGB reported, 1640 (8.6%) underwent LRYGB + endoscopy. This was broken down by SG only vs SG + endoscopy and LRYGB only vs LRYGB + endoscopy. Overall, SG + endoscopy had a significantly shorter length of stay (LOS) vs LRYGB + endoscopy at 1.74 d vs 2.34 d (P < .001) and a significantly less cost of $71,685 vs $91,093 (P < .001).

Conclusions

A small percentage of SG and LRYGB patients underwent endoscopy for provocative testing over the study period. Provocative testing with endoscopy costs more for SG and LRYGB and was associated with a shorter LOS.

The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study

INTRODUCTION

Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks.

METHODS

A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded.

RESULTS

924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1).

CONCLUSION

Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.