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Holzer-Stock CS, Pukaluk A, Viertler C, Regitnig P, Schweighofer M, Eschbach M, Caulk AW, Holzapfel GA. A biomechanical comparative study of passive stomach tissue from pigs and humans. Acta Biomater 2025:S1742-7061(25)00338-1. [PMID: 40389049 DOI: 10.1016/j.actbio.2025.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Revised: 04/09/2025] [Accepted: 05/05/2025] [Indexed: 05/21/2025]
Abstract
The prevalence of gastric problems, which are associated with high economic costs and medical complexity, is soaring worldwide. In biomedical research, porcine models have been widely used to investigate the gastrointestinal tract in preclinical studies due to their similar functionality and macrostructure. Despite their widespread acceptance, there is insufficient research on whether porcine gastric tissue accurately reflects the biomechanics and microstructure of the human stomach. Hence, the present study aims to characterize the human stomach wall and investigate inter-species differences and similarities through a comparison with a preceding study. For this purpose, quasi-static mechanical tests were performed in several deformation modes, i.e., planar biaxial extension, radial compression, and simple shear. The cyclic experiments were complemented by stress-relaxation tests to examine the viscoelastic behavior. Samples from two main layers of the stomach, i.e., mucosa and muscularis, as well as the complete stomach wall were tested from all gastric regions, i.e., fundus, body, and antrum. Through this strategic testing approach, considerable softening effects and various region- and layer-specific variations in the mechanical behavior of the stomach wall were observed. Complementary histological investigations highlighted the heterogeneous stomach wall architecture and its influence on the mechanical tissue response. The present study revealed significant regional, layer-, and sex-specific differences in the human stomach of patients undergoing bariatric surgery. The male stomach wall was thicker, more extensible in the antrum, and stiffer under radial compression in the fundus compared to the female cohort. Furthermore, notable differences were observed between porcine and human tissue, such as a significantly softer tissue response to radial compression and simple shear of the human muscularis and the complete stomach wall due to a higher collagen and elastin content and smaller muscle bundles.
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Affiliation(s)
| | - Anna Pukaluk
- Institute of Biomechanics, Graz University of Technology, Austria
| | - Christian Viertler
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Austria
| | | | | | | | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Austria; Department of Structural Engineering, NTNU, Trondheim, Norway.
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Endo Y, Orimoto H, Nakamura S, Miyoshino W, Nagasawa Y, Kawano Y, Takayama H, Masuda T, Hirashita T, Inomata M. Factors Affecting Histological Gastric Wall Thickness in Japanese Patients with Obesity. Obes Surg 2025; 35:946-951. [PMID: 39939574 PMCID: PMC11906570 DOI: 10.1007/s11695-025-07735-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 01/29/2025] [Accepted: 02/04/2025] [Indexed: 02/14/2025]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become a widely utilized surgical procedure for losing weight since its approval for insurance coverage in Japan in 2014. Its efficacy has been demonstrated by research, but data concerning gastric wall thickness following surgery remain unavailable. Hence, this study aimed to measure gastric wall thickness in resected, formalin-fixed specimens and explore the influence of obesity-related comorbidities on these measurements. METHODS This prospective study included 53 patients undergoing bariatric surgery at Oita University Hospital. Full-layer thickness (FLT) and muscle-layer thickness (MLT) in the antrum, body, and fornix of resected gastric specimens were measured. Data on patient demographics, comorbidities, and surgical procedure were also collected and analyzed using JMP software. Furthermore, associations between gastric wall thickness and patient factors were assessed. RESULTS The mean FLT in the antrum, body, and fornix was 2.9, 2.6, and 2.3 mm, with corresponding MLT of 1.2, 1.0, and 0.9 mm, respectively. The antrum exhibited the thickest gastric wall, whereas the fornix was the thinnest. Diabetes mellitus (DM) was associated with decreased MLT in the fornix, and obstructive sleep apnea (OSA) affected both FLT and MLT in the antrum. CONCLUSIONS Comorbidities such as DM and OSA significantly influence gastric wall thickness, particularly in the antrum and fornix. Understanding these variations is critical for optimizing surgical techniques and selecting the right stapler in LSG.
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Leon S, Rouhi AD, Ginzberg SP, Perez JE, Tewksbury CM, Gershuni VM, Altieri MS, Williams NN, Dumon KR. Perioperative Outcomes of Staple Line Reinforcement During Laparoscopic and Robotic Sleeve Gastrectomy: An MBSAQIP Cohort Study of 284,580 Patients. Obes Surg 2025; 35:992-1000. [PMID: 39903415 DOI: 10.1007/s11695-025-07727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Revised: 12/11/2024] [Accepted: 01/28/2025] [Indexed: 02/06/2025]
Abstract
BACKGROUND This study evaluated the association between staple line reinforcement (SLR) and 30-day outcomes in patients undergoing laparoscopic (LSG) or robotic sleeve gastrectomy (RSG). METHODS Adults undergoing primary LSG or RSG with and without SLR were analyzed from the 2018-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) database. Baseline characteristic differences by SLR status for LSG and RSG were adjusted using entropy balancing. Multivariable weighted logistic and linear regression was then performed to examine the association between SLR and primary and secondary outcomes. RESULTS Of 284,580 patients, 88.6% (n = 252,035) had LSG and 11.4% (n = 32,545) had RSG, of which 63.7% (n = 160,545) and 50.8% (n = 16,541) had SLR, respectively. Compared to LSG and RSG without SLR, both LSG and RSG with SLR encountered higher adjusted odds of emergency department visit (AOR 1.08, 95%CI 1.03-1.10, p < 0.001; AOR 1.10, 95%CI 1.01-1.20, p = 0.029, respectively) as well as lower adjusted odds of leakage (AOR 0.85, 95%CI 0.76-0.94, p = 0.002; AOR 0.71, 95%CI 0.54-0.92, p = 0.011, respectively) and gastrointestinal bleeding (AOR 0.79, 95%CI 0.77-0.91, p < 0.001; AOR 0.77, 95%CI 0.70-0.84, p < 0.001, respectively). LSG with SLR was also associated with greater odds of unplanned intubation (AOR 1.52, 95%CI 1.16-1.99, p = 0.002) and mechanical ventilation (AOR 1.74, 95%CI 1.22-2.50, p = 0.002). RSG with SLR was associated with higher odds of intraoperative conversion (AOR 1.71, 95%CI 1.15-2.54, p = 0.008), and lower odds of acute renal failure (AOR 0.27, 95%CI 0.11-0.65, p = 0.003). CONCLUSIONS This entropy-balanced analysis of the MBSAQIP registry demonstrated an overall association between SLR and lower postoperative leakage and bleeding after RSG and LSG.
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Affiliation(s)
- Sebastian Leon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Armaun D Rouhi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Sara P Ginzberg
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan E Perez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen M Tewksbury
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria S Altieri
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Noel N Williams
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Holzer CS, Pukaluk A, Viertler C, Regitnig P, Caulk AW, Eschbach M, Contini EM, Holzapfel GA. Biomechanical characterization of the passive porcine stomach. Acta Biomater 2024; 173:167-183. [PMID: 37984627 DOI: 10.1016/j.actbio.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
The complex mechanics of the gastric wall facilitates the main digestive tasks of the stomach. However, the interplay between the mechanical properties of the stomach, its microstructure, and its vital functions is not yet fully understood. Importantly, the pig animal model is widely used in biomedical research for preliminary or ethically prohibited studies of the human digestion system. Therefore, this study aims to thoroughly characterize the mechanical behavior and microstructure of the porcine stomach. For this purpose, multiple quasi-static mechanical tests were carried out with three different loading modes, i.e., planar biaxial extension, radial compression, and simple shear. Stress-relaxation tests complemented the quasi-static experiments to evaluate the deformation and strain-dependent viscoelastic properties. Each experiment was conducted on specimens of the complete stomach wall and two separate layers, mucosa and muscularis, from each of the three gastric regions, i.e., fundus, body, and antrum. The significant preconditioning effects and the considerable regional and layer-specific differences in the tissue response were analyzed. Furthermore, the mechanical experiments were complemented with histology to examine the influence of the microstructural composition on the macrostructural mechanical response and vice versa. Importantly, the shear tests showed lower stresses in the complete wall compared to the single layers which the loose network of submucosal collagen might explain. Also, the stratum arrangement of the muscularis might explain mechanical anisotropy during tensile tests. This study shows that gastric tissue is characterized by a highly heterogeneous microstructure with regional variations in layer composition reflecting not only functional differences but also diverse mechanical behavior. STATEMENT OF SIGNIFICANCE: Unfortunately, only few experimental data on gastric tissue are available for an adequate material parameter and model estimation. The present study therefore combines layer- and region-specific stomach wall mechanics obtained under multiple loading conditions with histological insights into the heterogeneous microstructure. On the one hand, the extensive data sets of this study expand our understanding of the interplay between gastric mechanics, motility and functionality, which could help to identify and treat associated pathologies. On the other hand, such data sets are of high relevance for the constitutive modeling of stomach tissue, and its application in the field of medical engineering, e.g., in the development of surgical staplers and the improvement of bariatric surgical interventions.
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Affiliation(s)
| | - Anna Pukaluk
- Institute of Biomechanics, Graz University of Technology, Austria
| | - Christian Viertler
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Austria
| | | | | | | | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Austria; Department of Structural Engineering, NTNU, Trondheim, Norway.
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Blumenthal M, Bertran J, Regier P, Cole J, Maxwell EA. Evaluation of automated staple sizes on gastric layer incorporation and intraluminal pressure for partial gastrectomy closure in an ex vivo canine model. Vet Med Sci 2023; 9:2586-2593. [PMID: 37817443 PMCID: PMC10650250 DOI: 10.1002/vms3.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/24/2023] [Accepted: 09/22/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVE To evaluate the performance of automated staple sizes on a cadaveric canine partial gastrectomy model. METHODS Stomachs were transected through the gastric body axis and randomly allocated to two closure groups: Group B, thoracoabdominal (TA) stapler 3.5 mm staple cartridge (blue); Group G, TA stapler 4.8 mm staple cartridge (green). After construct completion, leak testing was performed for both groups and compared. Initial leakage pressure (ILP), maximal leakage pressure (MLP) and leakage location were recorded. Staple lines were evaluated by direct observation and fluoroscopy to assess sub-mucosal layer incorporation and staple conformation. Staple shape was classified as optimal or suboptimal. Significance was set at p less than 0.5. RESULTS Following gastrectomy, the mean double gastric wall thickness was 7.82 ± 2.05 mm at the gastric body. Mean ILP was significantly lower in groups G (17.13 ± 1.19 mmHg) compared to group B (50.46 ± 6.03 mmHg, p = 0.0013). Similarly, mean MLP was significantly lower in group G (21.41 ± 1.39 mmHg) compared to group B (64.61 ± 10.21 mmHg, p < 0.0001). Although group G had higher percentage of B-shaped staple formation compared to group B, this was not significant (group G; 92.38%, group B; 54.56%; p = 0.054). CONCLUSION The 3.5 mm TA staple cartridge (blue) achieved superior bursting pressures compared with the 4.8 mm TA staple cartridge (blue) for the closure of a canine partial gastrectomy model. Both staple sizes incorporated all gastric layers. No differences were noticed in optimal staple conformation between groups. In vivo investigation is warranted to evaluate the use of different staple sizes on gastric tissue perfusion, successful healing and post-operative stasis and dehiscence.
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Affiliation(s)
- Michael Blumenthal
- Small Animal Clinical Sciences DepartmentUniversity of FloridaGainesvilleFloridaUSA
| | - Judith Bertran
- Small Animal Clinical Sciences DepartmentUniversity of FloridaGainesvilleFloridaUSA
| | - Penny Regier
- Small Animal Clinical Sciences DepartmentUniversity of FloridaGainesvilleFloridaUSA
| | - James Cole
- Small Animal Clinical Sciences DepartmentUniversity of FloridaGainesvilleFloridaUSA
| | - Elizabeth A Maxwell
- Small Animal Clinical Sciences DepartmentUniversity of FloridaGainesvilleFloridaUSA
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Kitaghenda FK, Shu C, Wang J, Hong J, Yao L, Zhu X. Measurement of gastric wall thickness after laparoscopic sleeve gastrectomy: obesity comorbidities and gastric wall in Chinese patients with obesity. Updates Surg 2023:10.1007/s13304-023-01538-z. [PMID: 37258849 DOI: 10.1007/s13304-023-01538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023]
Abstract
Leakage of the sleeve remains constant after laparoscopic sleeve gastrectomy (LSG). This complication may be due to a mismatch between the staple height and gastric wall thickness (GWT). Our aim was to measure the GWT in Chinese patients with obesity and investigate the relationship between GWT and gender, body mass index (BMI), body weight, and obesity-related comorbidities. The GWT of 210 resected specimens after LSG was measured using a tissue measuring device, at a compression pressure of 8 g/mm2 at three predetermined locations: antrum, midbody, and fundus. Two hundred ten patients (171 female/39 male). The gastric wall was thickest at the antrum followed by the midbody and thinnest at the fundus (3.02 mm, 2.22 mm, and 1.6 mm, respectively). Patients with gastritis and those with reflux esophagitis had thicker GWT at the antrum; male had thicker GWT at the antrum and fundus; patients with body weight > 100 kg, and those with BMI > 40 kg/m2 had thicker GWT at the fundus. Linear regression analysis revealed a significant association between GWT with body weight and BMI at the antrum and fundus; Furthermore, hypertension associated with the GWT at the fundus (P < 0.01, P < 0.01, P < 0.02, P < 0.01; and P < 0.04, respectively). This study showed that the anatomical location of the gastric wall is a major predicting factor of GWT. Furthermore, gastritis, reflux esophagitis, male gender, BMI > 40 kg/m2, body weight > 100 kg, and hypertension may increase the GWT at the antrum and fundus in Chinese patients with obesity.
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Affiliation(s)
- Fidele Kakule Kitaghenda
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Chang Shu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Jian Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Jian Hong
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Libin Yao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China.
| | - Xiaocheng Zhu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, People's Republic of China.
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Raj PP, Gupta P, Kumar SS. Laparoscopic Sleeve Gastrectomy: Late (>30-Days) Complications – Diagnosis and Management. OBESITY, BARIATRIC AND METABOLIC SURGERY 2023:479-493. [DOI: 10.1007/978-3-030-60596-4_84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Bigolin AV, Iaroseski J, de Lima JNC, Machry MC, Bonamigo ER, Grossi JVM, Fonseca MK, Silveira IVD. Optimization of Surgical Time Through the Implementation of a Rational Protocol to Prevent Bleeding in Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2023; 33:15-20. [PMID: 35731002 DOI: 10.1089/lap.2022.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Introduction: Staple line oversewing (SLO) is a prophylactic alternative due to its low cost and its effect of decreasing the incidence and severity of bleeding complications in sleeve gastrectomy (SG). However, this approach significantly increases the surgical time and may be associated with stenosis. The study aims to identify whether its usage was sufficient to optimize the surgical time in patients whose screening for the risk of occult bleeding was negative. Materials and Methods: The study enrolled 103 patients. Having the systolic blood pressure goal of 140 mmHg, the staple line is checked for bleeding points, counting as follows: >5 bleeding points proceed to SLO, <5 bleeding points are managed using clips, and if no bleeding points are found, the procedure can be completed. Results: The bleeding test was positive in 79.6% of the cases and oversewing was necessary for 44.7% of the total. The bleeding test result was significant for the increased surgical time. The mean surgical time in SLO was 16.4% higher than in clipping. There was a significant difference in surgical time between SLO and clipping; however, no significant difference was identified between clipping and continuing the procedure without further measures. No postoperative complication related to staple line bleeding was identified. Discussion: In a scenario with limitations for the use of high-cost homeostatic agents, the stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time without significant added risks. Conclusion: A stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time.
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Affiliation(s)
- André Vicente Bigolin
- Digestive Surgery Department, Santa Casa de Misericórdia Hospital, Porto Alegre, Brazil.,Nutrition Department, Cardiology Institute, University Foundation of Cardiology, Porto Alegre, Brazil
| | - Júlia Iaroseski
- Digestive Surgery Department, Santa Casa de Misericórdia Hospital, Porto Alegre, Brazil.,Medical Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | | | - Mayara Christ Machry
- Digestive Surgery Department, Santa Casa de Misericórdia Hospital, Porto Alegre, Brazil
| | | | | | | | - Izabele Vian da Silveira
- Nutrition Department, Cardiology Institute, University Foundation of Cardiology, Porto Alegre, Brazil
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Ramos AC, Bastos ELDS. Anatomical Considerations. DUODENAL SWITCH AND ITS DERIVATIVES IN BARIATRIC AND METABOLIC SURGERY 2023:219-228. [DOI: 10.1007/978-3-031-25828-2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Barski K, Binda A, Jaworski P, Gonciarska A, Kudlicka E, Żurkowska J, Wawiernia K, Tałałaj M, Wąsowski M, Tarnowski W. Influence of preoperative weight loss on gastric wall thickness-analysis of laparoscopic sleeve gastrectomy histological material. Langenbecks Arch Surg 2022; 407:3315-3322. [PMID: 36074187 DOI: 10.1007/s00423-022-02668-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/26/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE The variables possibly enabling the prediction of gastric wall thickness during laparoscopic sleeve gastrectomy remain undetermined. The aim of the study was to identify preoperative factors affecting gastric wall thickness in patients undergoing laparoscopic sleeve gastrectomy. METHODS The measurements of the double-wall thickness of gastric specimen excised during sleeve gastrectomy were taken at three locations after 15 s of compression with an applied pressure of 8 g/mm2. Statistical calculations were used to determine the influence of preoperative weight loss and other perioperative parameters on gastric wall thickness. RESULTS The study involved one hundred patients (78 female; 22 male). The thickest tissue was observed at the antrum with the mean value 2.55 mm (range 1.77-4.0 mm), followed by the midbody, mean 2.13 mm (range 1.34-3.20 mm), and the fundus, mean 1.69 mm (range 0.99-2.69 mm). Positive relationships were found between gastric wall thickness and both preoperative weight loss and age in all three measured locations; p < 0.05. In a linear regression model, age and preoperative weight loss were found to be statistically significant and positive predictors of higher gastric wall thickness only at the antrum. Male patients were observed to have thicker gastric wall at all three locations as compared to female patients. CONCLUSION Preoperative weight loss should be considered an important factor influencing gastric wall thickness. Age and gender can also be helpful in predicting the varying tissue thickness. Anatomical region is a key factor determining thickness of the stomach walls.
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Affiliation(s)
- Krzysztof Barski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Artur Binda
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland.
| | - Paweł Jaworski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Agnieszka Gonciarska
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Emilia Kudlicka
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Joanna Żurkowska
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Karolina Wawiernia
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Marek Tałałaj
- Geriatrics, Internal Medicine and Metabolic Bone Diseases Department, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Michał Wąsowski
- Geriatrics, Internal Medicine and Metabolic Bone Diseases Department, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Wiesław Tarnowski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
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Aboueisha MA, Freeman M, Allotey JK, Evans L, Caposole MZ, Tatum D, Levy S, Baker JW, Galvani C. Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database. Surg Endosc 2022; 37:3090-3102. [PMID: 35927350 DOI: 10.1007/s00464-022-09452-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mohamed A Aboueisha
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Meredith Freeman
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Jonathan K Allotey
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Leah Evans
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Michael Z Caposole
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Danielle Tatum
- Department of Surgery, Tulane University, New Orleans, LA, 70112, USA
| | - Shauna Levy
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - John W Baker
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Carlos Galvani
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA.
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Iannelli A, Chierici A, Castaldi A, Drai C, Schneck AS. Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy. Obes Surg 2022; 32:2605-2610. [PMID: 35696051 DOI: 10.1007/s11695-022-06152-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding. METHODS Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance. RESULTS One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5 days, p < 0.001). CONCLUSIONS Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.
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Affiliation(s)
- Antonio Iannelli
- Université Côte d'Azur, Nice, France.
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France.
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Andrea Chierici
- Service de Chirurgie Digestive, Centre Hospitalier d'Antibes Juan-Les-Pins, 107, av. de Nice, 06600, Antibes, France
| | - Antonio Castaldi
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Céline Drai
- Université Côte d'Azur, Nice, France
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, 97159, Pointe à Pitre, Guadeloupe
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Madhok B, Nanayakkara K, Mahawar K. Safety considerations in laparoscopic surgery: A narrative review. World J Gastrointest Endosc 2022; 14:1-16. [PMID: 35116095 PMCID: PMC8788169 DOI: 10.4253/wjge.v14.i1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/11/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.
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Affiliation(s)
- Brij Madhok
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kushan Nanayakkara
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kamal Mahawar
- Department of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR4 7TP, United Kingdom
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14
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Woodman GE, Voeller GR. Sleeve Gastrectomy Performed with Single Staple Height and Bioabsorbable Reinforcement in a Single Surgeon > 2500 Consecutive Case Series: Is Smart Technology Necessary? Obes Surg 2022; 32:690-695. [PMID: 34989973 DOI: 10.1007/s11695-021-05880-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is shown to have durable and sustained weight reduction outcomes and improvement in comorbid conditions in patients with severe clinical obesity. Discussions regarding "proper" staple height for various gastric locations continue. We propose a standard approach of consistent use of single staple load height and bioabsorbable staple line reinforcement during the LSG to reduce variability. METHODS A retrospective chart review of 2556 consecutive cases of adult patients who underwent LSG evaluated perioperative complications, postoperative leaks or bleeding, and average weight and body mass index (BMI) change and excess weight loss (EWL) at 6, 12, and 24 months. The same green staple load (2.0 mm) and staple line reinforcement were used in all cases for all staple firings, regardless of patient size or gastric location. RESULTS Patients were a mean age of 42 years, 87.3% were female, and the mean preoperative weight was 134.2 kg and BMI was 48.2 kg/m2. No staple line leak was detected. Three bleeding events occurred but did not require readmission or rehospitalization. Mean EWL and BMI, respectively, were 49.0% and 35.5 kg/m2 at 6 months, 69.8% and 29.6 kg/m2 at 12 months, and 70.0% and 29.5 kg/m2 at 24 months. CONCLUSION In this case series of 2556 consecutive LSG performed by a single surgeon, clinically meaningful EWL and decreased BMI were achieved. Streamlining the LSG procedure by utilizing the same staple height and a bioabsorbable staple line reinforcement proved safe with minimal complications.
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Affiliation(s)
| | - Guy R Voeller
- Health Science Center and Baptist Medical Group, University of Tennessee, Memphis, TN, 38163, USA
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Endo Y, Ohta M, Kawamura M, Fujinaga A, Nakanuma H, Watanabe K, Kawasaki T, Masuda T, Hirashita T, Inomata M. Gastric Wall Thickness and Linear Staple Height in Sleeve Gastrectomy in Japanese Patients with Obesity. Obes Surg 2021; 32:349-354. [PMID: 34783958 DOI: 10.1007/s11695-021-05758-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a standard procedure due to its low complication rates and favorable outcomes. However, limited data are available regarding the optimal size of linear staplers in relation to gastric wall thickness (GWT). METHODS Between August 2016 and December 2020, we performed LSG in 70 patients with an average age, body weight, and body mass index of 42 years, 107 kg, and 40 kg/m2, respectively. We measured the GWT at the antrum, body, and fundus using resected specimens. We used an endo-linear stapler, and the closed staple height (CSH) was 1.75 mm. RESULTS We found that the average GWT at the antrum was significantly thicker than the GWT at the body and fundus. There was a statistically significant relationship between body weight and the GWT at the antrum and body and obstructive sleep apnea and the GWT at the body. The average CSH/GWT ratios were 0.55, 0.62, and 0.90 at the antrum, body, and fundus, respectively. However, in 20 patients (29%), the CSH/GWT ratio at the fundus area was ≥ 1.0, and only preoperative body weight was a significant predictor for a CSH/GWT ratio of ≥ 1.0. CONCLUSION A light body weight may be related to a CSH/GWT ratio of ≥ 1.0 at the fundus.
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Affiliation(s)
- Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan.,Global Oita Medical Advanced Research Center for Health, Oita University, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Hiroaki Nakanuma
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Kiminori Watanabe
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita, 879-5593, Japan
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Boeker C, Schneider B, Markov V, Mall J, Reetz C, Wilkens L, Hakami I, Stroh C, Köhler H. Primary Sleeve Gastrectomy and Leaks: The Impact of Fundus-Wall Thickness and Staple Heights on Leakage-An Observational Study of 500 Patients. Front Surg 2021; 8:747171. [PMID: 34746223 PMCID: PMC8566748 DOI: 10.3389/fsurg.2021.747171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated. Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%). Results: The mean thickness of the proximal fundus wall was 2,904 μm, 3,172 μm in men and 2,784 μm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05. Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.
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Affiliation(s)
- Clara Boeker
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | | | - Valentin Markov
- Department of Psychology, University of Hildesheim, Hildesheim, Germany
| | - Julian Mall
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | - Christian Reetz
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | - Ludwig Wilkens
- Department of Pathology, Klinikum Nordstadt, Hannover, Germany
| | - Ibrahim Hakami
- Department of General, Visceral and Bariatric Surgery, College of Medicine at Jazan University, Jizan, Saudi Arabia
| | - Christine Stroh
- Department of Bariatric Surgery, Stiftung Rehabilitation Heidelberg Waldklinikum, Gera, Germany
| | - Hinrich Köhler
- Department of General, Visceral and Bariatric Surgery, Herzogin Elisabeth Hospital, Braunschweig, Germany
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17
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Patrzyk M, Sonke J, Glitsch A, Kessler R, Steveling A, Lünse S, Partecke LI, Heidecke CD, Kessler W. Gastric Balloon Implantation as Part of Morbid Adiposity Therapy Changes the Structure of the Stomach Wall. Visc Med 2021; 37:418-425. [PMID: 34722725 PMCID: PMC8543320 DOI: 10.1159/000514264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/04/2021] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The implantation of a gastric balloon (also known as intragastric balloon) is an established and reversible endoscopic procedure for adiposity therapy. Structural changes of the stomach wall are expected to occur with gastric balloon implantation; however, until now these changes have rarely been investigated. METHODS We compared the histological structure of the stomach wall after gastric-sleeve resection in a group of patients following gastric balloon implantation and a group without previous gastric balloon implantation. RESULTS Following gastric balloon implantation, the tunica muscularis was found to be significantly thicker than without gastric balloon implantation. The enlarging of the tunica muscularis is not caused by hyperplasia of the leiomyocytes, but by hypertrophy of the leiomyocytes and an increase in collagen fibers (fibrosis). CONCLUSION A longer-lasting hypertrophy of the tunica muscularis, particularly in the corpus, should be taken into account when surgical treatment follows gastric balloon implantation. The staple suture height should be adjusted to the altered tissue composition since reduced tissue elasticity must be expected due to fibrosis.
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Affiliation(s)
- Maciej Patrzyk
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
| | - Jenny Sonke
- Department of Pathology, University Medical Center Greifswald, Greifswald, Germany
| | - Anne Glitsch
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
| | - Rebecca Kessler
- Department of Diagnostic Radiology and Neuroradiology, University Medical Center Greifswald, Greifswald, Germany
| | - Antje Steveling
- Department of Internal Medicine A, University Medical Center Greifswald, Greifswald, Germany
| | - Sebastian Lünse
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
| | - Lars Ivo Partecke
- Department of General, Visceral and Thoracic Surgery, Helios-Klinikum Schleswig, Schleswig, Germany
| | - Claus-Dieter Heidecke
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
| | - Wolfram Kessler
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
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18
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Salyer C, Spuzzillo A, Wakefield D, Gomaa D, Thompson J, Goodman M. Endocutter Staple Height Auto-adjusts to Tissue Thickness. J Surg Res 2021; 267:705-711. [PMID: 34364256 DOI: 10.1016/j.jss.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/04/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgeon choice of the appropriate staple height has been cited as a factor in the mechanical integrity of a staple line. However, tissue measured at the industry standard 8 g/mm2 is usually thicker than the formed staple height of the staples that hold it together. This means that the pressure that the staples apply must be greater than 8g/mm2. Additionally, formed staple heights in tissue may be different than formed staple heights of the same cartridge type when fired without tissue. This means that there is likely a compressive limit to the individual staples deployed by the stapling system. The purpose of this study is to establish the degree to which staple heights of endocutter staples auto-adjust to tissue and the compressive limit to tissue that this infers. MATERIALS AND METHODS Excised gastric remnants from laparoscopic sleeve gastrectomy were measured for tissue thickness at different external pressures. An optimized experimental staple line was then created in parallel to the clinical staple line. The doubly-stapled gastric sliver then underwent computed tomography with solid modeling software to measure staple heights. RESULTS Staple heights fired in gastric tissue were significantly different than industry labelled and control staple heights. Clinical staple heights were significantly shorter than measured tissue thickness at 8 g/mm2. Staple height more closely approximated tissue thickness under 15 g/mm2 of pressure, rather than the 8 g/mm2 loading pressure used by industry for tissue thickness range labelling. CONCLUSIONS Staples deployed in human gastric tissue are taller than commercial labelling. The closed staple height corresponds to tissue thickness under 15g/mm2 of pressure, not the labelled staple height. These results demonstrate that staple heights from modern endocutter staplers adjust to tissue, approximating a maximum compressive force just above 15g/mm2.
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Affiliation(s)
- Christen Salyer
- Division of Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Anthony Spuzzillo
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Devin Wakefield
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Dina Gomaa
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jonathan Thompson
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio; Standard Bariatrics, Inc. Cincinnati, Ohio
| | - Michael Goodman
- Section of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio.
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Abstract
BACKGROUND Sleeve gastrectomy has been considered a primary bariatric surgery; however, surgeons concerned with staple line leakage often query whether staples selected during stomach resection are of an appropriate size. This study aimed to measure gastric wall thickness using pathology laboratory measurements and to identify variables correlated with stomach wall thickness in patients who had undergone laparoscopic sleeve gastrectomy. METHODS We obtained fresh resected stomach wall specimens from 30 patients. Stomach wall thickness was immediately measured postoperatively, comprising the muscle layer of the antrum, body, and fundus. Results were correlated with body mass index (BMI), age, and sex and with diagnoses of presurgical diabetes, hypertension, hyperlipidemia, and fatty liver. RESULTS Stomach wall thickness ranged from 3.4 ± 4.3 mm to 1.0 ± 9.6 mm at the antrum. Except for the whole layer at the body wall, there was no significant correlation between wall thickness and other factors. At the body wall, whole layer wall thickness was found to positively correlate with age, sex, diabetes, and smoking (r = 0.469, - 0.391, 0.396, and 0.349, respectively; p < 0.05 in all patients). CONCLUSION Stomach wall thickness varied among patients who had undergone laparoscopic sleeve gastrectomy according to samples taken at three stomach wall sites. The range in wall thickness was normal, and thus, surgeons need not hesitate in selecting the staple height. Also, our study may be helpful to guide surgeon choice concerning the third or fourth staple around the body area when considering a patient's independent factors.
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20
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Yeo E, Thompson J, Hanseman D, Dunki-Jacobs A, Thompson B, Goodman M, Diwan T. Increased staple loading pressures and reduced staple heights in laparoscopic sleeve gastrectomy reduce intraoperative bleeding. Surgery 2020; 169:1110-1115. [PMID: 33261823 DOI: 10.1016/j.surg.2020.10.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/22/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In laparoscopic sleeve gastrectomy, tissue thickness and closed staple height of the staple cartridge determine the pressure applied to the tissue. Prior studies have suggested 8 g/mm2 to be ideal to minimize leaks or bleeding. METHODS We evaluated the relationship between staple loading pressure applied to gastric tissue and bleeding rate prospectively with a novel tissue measuring device and video-recorded operative findings for 116 patients undergoing laparoscopic sleeve gastrectomy performed by 2 surgeons at a single institution. Stapling protocol 1 was used for 64 cases, defined as standard practice, typically using green-blue-blue-blue Ethicon staple cartridges. Stapling protocol 2 was defined as blue-blue-white-white or gold-blue-white-white. RESULTS Tissue thickness measurements from 39 cases and staple load selection showed that surgeons preferred a median staple loading pressure of 15 g/mm2. Tissue thickness measurements at 15 g/mm2 had a mean of 1.86 mm at the antrum, 1.71 mm at the body, and 1.15 mm at the fundus, all significantly thinner than tissue thickness at 8 g/mm2. For each 10 g/mm2 increase in minimum pressure and maximum pressure value within each cartridge zone, there was a reduction in bleeding rate by 59.8% and 38.7%, respectively. Compared with stapling protocol 1, stapling protocol 2 had a lower intraoperative bleeding rate (90.2% vs 70.7%; P < .0001), usage of preventive hemostatic techniques (100% vs 10%; P < .0001), and hemostatic treatments (66% vs 46%; P = .04). In the 30-day postoperative period, there was 1 bleed in stapling protocol 1; there were no leaks. CONCLUSION Our data suggest using shorter closed staple heights to exert higher staple loading pressures decreases intraoperative bleeding rates in laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Eujin Yeo
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | - Jonathan Thompson
- Department of Surgery, University of Cincinnati School of Medicine, OH; Standard Bariatrics, Inc, Cincinnati, OH
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | | | | | - Michael Goodman
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | - Tayyab Diwan
- Department of Surgery, University of Cincinnati School of Medicine, OH; Mayo Clinic Rochester, MN.
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21
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Mullen KM, Regier PJ, Ellison GW, Londoño L. The Pathophysiology of Small Intestinal Foreign Body Obstruction and Intraoperative Assessment of Tissue Viability in Dogs: A Review. Top Companion Anim Med 2020; 40:100438. [PMID: 32690289 DOI: 10.1016/j.tcam.2020.100438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 12/29/2022]
Abstract
Small intestinal foreign body obstructions occur commonly in dogs, accounting for 80% of all canine intestinal obstructions. Such obstructions induce local aberrations in secretion, absorption, and intestinal motility that can precipitate devastating systemic consequences, including a systemic inflammatory response, sepsis, and multiorgan dysfunction. Radiographic diagnosis is poorly sensitive relative to ultrasonography for diagnosing the presence of obstructive foreign material. Emergent surgical intervention is indicated for dogs with obstructive foreign material due to an inability to assess the degree of compromise of the intestinal wall that may precipitate intestinal perforation and to mitigate progression of life-threatening electrolyte and acid-base imbalances secondary to sequestration and emesis. Intraoperatively, an enterotomy or resection and anastomosis may be required to remove the obstructive material. A number of subjective and objective techniques for assessing the viability of intestinal tissue have been described due to the poor accuracy associated with surgeon assessment of color, peristalsis, pulsation, bleeding, and mural thickness alone. Such techniques have the potential to alter the surgeon's decision-making regarding performance of an enterotomy or resection and anastomosis, potentially reducing morbidity associated with intestinal surgery.
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Affiliation(s)
- Kaitlyn M Mullen
- University of Florida, Department of Small Animal Clinical Sciences, Gainesville, FL, USA
| | - Penny J Regier
- University of Florida, Department of Small Animal Clinical Sciences, Gainesville, FL, USA.
| | - Gary W Ellison
- University of Florida, Department of Small Animal Clinical Sciences, Gainesville, FL, USA
| | - Leonel Londoño
- University of Florida, Department of Small Animal Clinical Sciences, Gainesville, FL, USA
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22
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An Experimental Study of Intraluminal Hyperpressure Reproducing a Gastric Leak Following a Sleeve Gastrectomy. Obes Surg 2019; 29:2773-2780. [DOI: 10.1007/s11695-019-03924-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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23
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Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review. Surg Endosc 2019; 34:396-407. [PMID: 30993513 PMCID: PMC6946737 DOI: 10.1007/s00464-019-06782-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
Abstract
Background Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM). Methods This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options. Results Of the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS). Conclusions This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates. Electronic supplementary material The online version of this article (10.1007/s00464-019-06782-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michel Gagner
- Department of Surgery, Hopital du Sacré Coeur, 315 Place D’Youville, Suite 191, Montréal, QC H2Y 0A4 Canada
- Herbert Wertheim School of Medicine, Florida International University, Miami, FL USA
- Westmount Square Surgical Center, Westmount, QC Canada
| | - Paul Kemmeter
- Department of Surgery, Mercy Health Saint Mary’s, 2060 E Paris Ave SE #100, Grand Rapids, MI USA
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Lundvall E, Ottosson J, Stenberg E. The influence of staple height on postoperative complication rates after laparoscopic gastric bypass surgery using linear staplers. Surg Obes Relat Dis 2019; 15:404-408. [PMID: 30738736 DOI: 10.1016/j.soard.2019.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND The use of circular staplers with a low staple height is associated with a lower risk for complication when used to construct the gastroenterostomy in laparoscopic gastric bypass surgery. The influence of staple height on outcome when using linear staplers has not been studied. OBJECTIVES To investigate the influence of staple height when constructing the gastric pouch and gastroenterostomy using a linear stapler in laparoscopic gastric bypass surgery. SETTING Nationwide, Sweden. METHODS A retrospective, register-based cohort study, including all primary laparoscopic gastric bypass surgical procedures in Sweden registered in the Scandinavian Obesity Surgery Registry from January 2010 until January 2017, where linear staplers were used to construct the gastric pouch and the gastroenterostomy. Low stapler heights (closed height ≤1.0 mm) were compared with higher stapler heights (closed height ≥1.5 mm). The main outcome was postoperative complication within 30 days of surgery. RESULTS Within the study period, 27,975 patients were identified from the Scandinavian Obesity Surgery Registry. A closed staple height ≥1.5 mm was associated with higher risk for postoperative complication within 30 days of surgery compared with lower staple height. The risk was greater when used to construct the gastric pouch (adjusted odd ratio 1.30, 95% confidence interval 1.17-1.44, P < .001) as well as when constructing the gastroenterostomy (adjusted odd ratio 1.32, 95% confidence interval 1.20-1.45, P < .001). CONCLUSION The use of low staple height for construction of the gastric pouch and gastroenterostomy in laparoscopic gastric bypass surgery was associated with lower complication rates.
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Affiliation(s)
- Emma Lundvall
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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25
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Iannelli A, Treacy P, Sebastianelli L, Schiavo L, Martini F. Perioperative complications of sleeve gastrectomy: Review of the literature. J Minim Access Surg 2019; 15:1-7. [PMID: 29737316 PMCID: PMC6293679 DOI: 10.4103/jmas.jmas_271_17] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 04/09/2018] [Indexed: 02/06/2023] Open
Abstract
Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.
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Affiliation(s)
- Antonio Iannelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
- Inserm, U1065, Team 8 “Hepatic Complications of Obesity”, Nice, France
- University of Nice Sophia Antipolis, Nice, Francea
| | - Patrick Treacy
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Lionel Sebastianelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Luigi Schiavo
- Department of Cardio-Thoracic and Respiratory Science, University of Campania “Luigi Vanvitelli”, Naples, Italy
- IX Division of General Surgery, Vascular Surgery and Applied Biotechnology, Naples University Polyclinic, Naples, Italy
| | - Francesco Martini
- Digestive and Bariatric Surgery Unit, Joseph Ducuing Hospital, Toulouse, France
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26
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Debs T, Petrucciani N, Kassir R, Sejor E, Karam S, Ben Amor I, Gugenheim J. 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. Surg Obes Relat Dis 2018; 14:1804-1810. [PMID: 30316829 DOI: 10.1016/j.soard.2018.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Tarek Debs
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France.
| | - Niccolo Petrucciani
- Division of Digestive Surgery and Liver Transplantation, UPEC University, Henri Mondor Hospital, Creteil, France
| | - Radwan Kassir
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Eric Sejor
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Sami Karam
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Imed Ben Amor
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Jean Gugenheim
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
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27
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Derici S, Atila K, Bora S. The Effect of the Cartridge Used in Laparoscopic Sleeve Gastrectomy on the Development of a Staple-Line Leak. Am Surg 2018. [DOI: 10.1177/000313481808400958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Serhan Derici
- From the Department of General Surgery, Dokuz Eylul University, Izmir, Turkey
| | - Koray Atila
- From the Department of General Surgery, Dokuz Eylul University, Izmir, Turkey
| | - Seymen Bora
- From the Department of General Surgery, Dokuz Eylul University, Izmir, Turkey
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Varban OA, Thumma JR, Finks JF, Carlin AM, Kemmeter PR, Ghaferi AA, Dimick JB. Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study. Surg Endosc 2018; 33:895-903. [DOI: 10.1007/s00464-018-6382-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
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29
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Thompson SE, Young MT, Lewis MT, Boronyak SM, Clymer JW, Fegelman EJ, Nagle DA. Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model. Obes Surg 2018; 28:3446-3453. [PMID: 29956107 DOI: 10.1007/s11695-018-3363-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak is a leading cause of morbidity and mortality in gastrointestinal surgery. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. We sought to assess the degree of mucosal capture when using stapling devices and determine whether incomplete capture influences staple line integrity. METHODS Porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a 5-point scale from 1 (mucosa mainly captured on both sides) to 5 (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was assessed. Stapling devices studied were Echelon Flex GST with 60-mm blue (GST60B) and green (GST60G) cartridges, and Medtronic EndoGIA Universal with Tri-Staple Technology™ with 60 mm medium (EGIA60AMT) reloads (purple). RESULTS GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p < 0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p < 0.001) and 23% higher for GST60G (p = 0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time. CONCLUSIONS There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures. Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.
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Affiliation(s)
| | - Maggie T Young
- Ethicon, Inc., 4545 Creek Rd, Cincinnati, OH, 45242, USA
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30
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Gray KD, Pomp A, Dakin G, Amanat S, Turnbull ZA, Samuels J, Afaneh C. Perioperative outcomes and anesthetic considerations of robotic bariatric surgery in a propensity-matched cohort of super obese and super-super obese patients. Surg Endosc 2018; 32:4867-4873. [PMID: 29766309 DOI: 10.1007/s00464-018-6241-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort. METHODS Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type. RESULTS A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1-92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1-48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8-3.2 vs. 1.8 days, IQR 1.2-2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60-92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset. CONCLUSIONS Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.
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Affiliation(s)
- Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Alfons Pomp
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Gregory Dakin
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Sonia Amanat
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Zachary A Turnbull
- Department of Anesthesia, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Jon Samuels
- Department of Anesthesia, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Cheguevara Afaneh
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, A1027, New York, NY, 10065, USA. .,Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA.
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31
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Gagner M. Comment on: antral resection versus antral preservation during laparoscopic sleeve gastrectomy for severe obesity: systematic review and meta-analysis. Surg Obes Relat Dis 2018; 14:864-866. [PMID: 29724683 DOI: 10.1016/j.soard.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Michel Gagner
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Hopital du Sacre Coeur, Montreal, Canada
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32
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Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg 2018. [DOI: 10.1177/000313481808400521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m22. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis ( P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intra-operative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.
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33
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Preoperative Detection of Sarcopenic Obesity Helps to Predict the Occurrence of Gastric Leak After Sleeve Gastrectomy. Obes Surg 2018; 28:2379-2385. [DOI: 10.1007/s11695-018-3169-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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34
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Gastric wall thickness and stapling in laparoscopic sleeve gastrectomy - a literature review. Wideochir Inne Tech Maloinwazyjne 2018; 13:122-127. [PMID: 29643968 PMCID: PMC5890851 DOI: 10.5114/wiitm.2018.73362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/14/2018] [Indexed: 11/29/2022] Open
Abstract
Despite the growing experience of bariatric surgeons in performing laparoscopic sleeve gastrectomy, the number of complications involving staple line leaks remains constant. Hence a solution to avoid such complications is still sought. A defect of the staple line may be the consequence of an inappropriate choice of staple size in relation to gastric wall thickness. Due to the variable nature of gastric wall thickness, the choice of proper staple height is not obvious. In the few studies in which gastric wall thickness was measured, it was observed to decrease gradually from the antrum to the fundus. However, the authors are divided on the issue of whether gender and body mass index influence gastric wall thickness. The question whether there are other perioperative factors that would allow gastric wall thickness to be predicted remains unanswered.
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35
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Gagner M. Comment on: an alternative view on the necessity of EGD prior to sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:1964-1965. [PMID: 29055667 DOI: 10.1016/j.soard.2017.09.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 09/21/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Michel Gagner
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Hopital du Sacre Coeur, Montreal, Canada
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36
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Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic bariatric surgery. Ann Gastroenterol 2017; 31:56-64. [PMID: 29333067 PMCID: PMC5759613 DOI: 10.20524/aog.2017.0201] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022] Open
Abstract
With over 600 million people being obese, and given the scientific demonstration of the advantages of surgical treatment, bariatric surgery is on the rise. The promising long-term results in terms of weight loss, and particularly in relation to comorbidities and the control/cure rate, mean that the number of procedures performed in all countries remains high. However, the risk of potentially complex or fatal complications, though small, is present and is related to the procedures per se. This review is a guide for bariatric and/or general surgeons, offering a complete overview of the pathogenesis of anastomosis and staple line following the most common laparoscopic bariatric procedures: sleeve gastrectomy, gastric bypass, and mini-gastric bypass. The review is divided according to the procedure and the complications (leak, bleeding and stenosis), and evaluates all the factors that can potentially improve or worsen the complication rate, representing a “unicum” in the present literature on bariatric surgery.
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Affiliation(s)
- Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Centre of Excellence, University of Rome "La Sapienza", Rome, Italy
| | - Angelo Iossa
- Department of Medical-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Centre of Excellence, University of Rome "La Sapienza", Rome, Italy
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37
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Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1738 Consecutive Procedures. Obes Surg 2017; 28:627-635. [PMID: 28840492 DOI: 10.1007/s11695-017-2907-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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38
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Varban OA, Niemann A, Stricklen A, Ross R, Ghaferi AA, Finks JF, Dimick JB. Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2017; 27:761-767. [PMID: 28686537 DOI: 10.1089/lap.2017.0184] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Video assessment is an emerging tool for understanding variation in surgical technique. METHODS Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured. RESULTS Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%). CONCLUSIONS LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.
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Affiliation(s)
- Oliver A Varban
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan
| | - Adam Niemann
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
| | - Amanda Stricklen
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Rachel Ross
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Amir A Ghaferi
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Jonathan F Finks
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan
| | - Justin B Dimick
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan.,3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
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39
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Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height—an Observational Cohort Study. Obes Surg 2017. [PMID: 28623446 DOI: 10.1007/s11695-017-2755-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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40
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Etiology of Leaks Following Sleeve Gastrectomy: Current Evidence. Surg Laparosc Endosc Percutan Tech 2017; 27:119-122. [DOI: 10.1097/sle.0000000000000400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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41
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Ilic M, Putnik SS. Surgical Technique: Laparoscopic Gastric Sleeve Resection in Super-Obese Patients. J INVEST SURG 2017; 31:165-167. [PMID: 28387579 DOI: 10.1080/08941939.2017.1289284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Laparoscopic gastric sleeve (LGS) resection in super-obese patients (BMI > 50 kg/m2) is a challenging procedure. We have developed a unique approach and technique for LGS with no buttress stapling and without oversewing. After 102 operations there have been no leaks and late complications.
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Affiliation(s)
- M Ilic
- a Clinic for Thoracic Surgery , Institute for Pulmonary Diseases of Vojvodina , Sremska Kamenica , Serbia.,b University of Novi Sad, Medical Faculty , Novi Sad , Serbia
| | - S S Putnik
- c Department of General Surgery , General Hospital Vrsac , Serbia
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42
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Abu-Ghanem Y, Meydan C, Segev L, Rubin M, Blumenfeld O, Spivak H. Gastric Wall Thickness and the Choice of Linear Staples in Laparoscopic Sleeve Gastrectomy: Challenging Conventional Concepts. Obes Surg 2016; 27:837-843. [DOI: 10.1007/s11695-016-2516-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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43
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Varban OA, Sheetz KH, Cassidy RB, Stricklen A, Carlin AM, Dimick JB, Finks JF. Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Surg Obes Relat Dis 2016; 13:560-567. [PMID: 28089439 DOI: 10.1016/j.soard.2016.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/10/2016] [Accepted: 11/29/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG). BACKGROUND Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood. METHODS We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10. RESULTS Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate<1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line. CONCLUSION Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.
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Affiliation(s)
- Oliver A Varban
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Ruth B Cassidy
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Amanda Stricklen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Arthur M Carlin
- Wayne State University, Detroit, Michigan; Department of Surgery, Henry Ford Health System, Dearborn, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
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Hussain A, Al-Shoek I, El-Hasani S. The Use of Tranexamic Acid in Sleeve Gastrectomy. Obes Surg 2016; 27:198-199. [PMID: 27718174 DOI: 10.1007/s11695-016-2409-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A Hussain
- Bariatric Unit, Doncaster Royal Infirmary, Doncaster, DN25LT, UK.
| | - I Al-Shoek
- Frimley Park NHS Foundation Trust, Frimley, UK
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The effect of oversewing the staple line in laparoscopic sleeve gastrectomy: randomized control trial. Wideochir Inne Tech Maloinwazyjne 2016; 11:149-155. [PMID: 27829937 PMCID: PMC5095279 DOI: 10.5114/wiitm.2016.62801] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/05/2016] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. The procedure is associated with serious staple-line complications such as bleeding, leaks, and stenosis. AIM To determine whether oversewing the staple line, compared with clipping, in LSG reduces the incidence of postoperative bleeding. MATERIAL AND METHODS We conducted a parallel-group, prospective, randomized controlled trial (RCT) of 100 patients who underwent LSG for obesity at a single institution between May 2014 and August 2015. Patients were assigned to one of two groups for reinforcement of the staple line: the oversewing group (staple line oversewn) or the clipping group (staple line clipped). The primary outcome was reoperation for hemodynamic instability caused by staple-line bleeding within 72 h postoperatively. The secondary outcomes were operative duration, length of hospital stay, postoperative leaks, and postoperative stenosis. RESULTS Mean operative duration was longer in the oversewing group (78.2 ±20.5 min) than in the clipping group (64.1 ±16.5 min, p < 0.001). Mean length of hospital stay was comparable in both groups. Postoperatively, there was no significant between-group difference in bleeding (oversewing, n = 0 vs. clipping, n = 2 (4.6%); p = 0.21) or in stenosis and leakage (both outcomes: oversewing, n = 0, vs. clipping, n = 1 (2.3%); p = 0.46). CONCLUSIONS Oversewing the staple line prolongs operative duration. No conclusions can be drawn regarding the effects of oversewing on staple-line bleeding, postoperative leakage and stenosis, or length of hospital stay.
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Iossa A, Abdelgawad M, Watkins BM, Silecchia G. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg 2016; 401:757-66. [PMID: 27301373 DOI: 10.1007/s00423-016-1464-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures. METHODS Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence. RESULTS Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage. CONCLUSIONS This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5-6 cm from the pylorus, EL:2-3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
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Affiliation(s)
- Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.
| | - Mohamed Abdelgawad
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.,Gastroenterology Surgical Center (GEC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Brad Michael Watkins
- Division of General Surgery and Weight loss Center, West Chester Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy
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Morandeira-Rivas A, Moreno-Sanz C, Clerveus M, Muñoz de la Espada-Merlo Córdoba JB, Herrero-Bogajo ML, Román-Ortiz C. Staple line reinforcement for adults undergoing bariatric surgery with gastric transection. Hippokratia 2015. [DOI: 10.1002/14651858.cd011853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Antonio Morandeira-Rivas
- Mancha Centro General Hospital; General and Digestive Surgery; Avd. De la Constitución No. 3 Alcázar de San Juan Ciudad Real Spain 13600
| | - Carlos Moreno-Sanz
- Mancha Centro General Hospital; General and Digestive Surgery; Avd. De la Constitución No. 3 Alcázar de San Juan Ciudad Real Spain 13600
| | - Michael Clerveus
- Mancha Centro General Hospital; General and Digestive Surgery; Avd. De la Constitución No. 3 Alcázar de San Juan Ciudad Real Spain 13600
| | | | - Mari Luz Herrero-Bogajo
- Mancha Centro General Hospital; General and Digestive Surgery; Avd. De la Constitución No. 3 Alcázar de San Juan Ciudad Real Spain 13600
| | - Carmen Román-Ortiz
- Mancha Centro General Hospital; Research Support Unit; Avd. de la Constitución 3 -Alcazar de San Juan -Ciudad Real Spain
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