Decreasing anastomotic and staple line leaks after laparoscopic Roux-en-Y gastric bypass

Background   Anastomotic and staple line leaks (ASL) occur after laparoscopic Roux-en-Y gastric bypass (LRYGB) with a reported incidence as high as 6%. Leaks are the second most common cause of post-LRYGB mortality after pulmonary embolism, and can be associated with significant morbidity. Prevention and early detection may limit both morbidity and mortality. Methods   A retrospective analysis of prospectively collected data was performed on all LRYGBs performed in a community hospital by a single surgeon from August 2001 to December 2005. All operations were performed using a linear-stapled anastomosis with buttressing material, handsewn otomy closures, stay sutures, intraoperative leak testing, and fibrin sealant. Results   760 patients underwent LRYGB during the study period. Eighty-nine percent (n = 674) were female and 11% (n = 86) were male. Mean body mass index (BMI) was 50 kg/m² (range 36–83 kg/m²). Mean age was 40 years (range 17–72 years). Two patients developed three gastric pouch staple line leaks (0.4%). There were no mortalities. Conclusion   Operative technique, including appropriate staple sizing, staple line reinforcement, handsewn otomy closures, placement of stay sutures, intraoperative leak testing, and placement of fibrin sealant contributed to a lower than expected incidence of ASL after LRYGB in this series.     

Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass

BackgroundSeveral publications have suggested that staple line buttressing might decrease staple line bleeding, increase burst pressure, and decrease the likelihood of acute failure resulting in leak. Currently, permanent and nonpermanent options are available. However, concern has been raised about the permanent buttress material and its potential for delayed strip expulsion. This study analyzed our experience with 3 different buttressing materials for creating the gastric division during laparoscopic Roux-en-Y gastric bypass.MethodsFrom July 5, 2001 to May 30, 2007, 1451 consecutive patients underwent laparoscopic gastric bypass with buttressing material used for the stapled creation of the gastric pouch. Peristrips Dry (PSDs), permanent bovine pericardial strips, were used in 926 cases from July 5, 2001 to October 11, 2005. Seamguards, a synthetic bioabsorbable product, were used in 145 cases from November 2, 2004 to July 18, 2006, and PSD Veritas, remodelable, nonpermanent bovine pericardial strips, were placed in 380 patients from October 11, 2005 to May 30, 2007. All products were applied to the 60-mm-long, 3.5-mm cartridges of the EndoGIA II stapler. The ease of use, operative complications, visual bleeding, and postoperative leaks were recorded.ResultsThe patient characteristics were comparable for all groups. All products were easy to load on the stapler, and no operative complications related to the use of the buttress materials occurred. The incidence and severity of staple line bleeding was not specifically calculated but was visually noted to be minimal in all cases. Of the 3 groups, 4 contained leaks occurred in the Seamguards group, and all were successfully managed nonoperatively. No acute leaks were discovered in the PSD or PSD Veritas groups. This difference was statistically significant (p <.001).ConclusionNeither the PSDs or PSD Veritas group exhibited staple line complications. However, 4 leaks occurred in the patients who had Seamguards incorporated into their gastric pouch linear staple lines.     

Reinforcement Does Not Necessarily Reduce the Rate of Staple Line Leaks After Sleeve Gastrectomy. A Review of the Literature and Clinical Experiences

Background  Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause. Methods  The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks. Results  Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41–3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures. Conclusions  There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.     

Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75-182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4-78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.     

Shorter circular staple is height associated with lower anastomotic stricture rate in laparoscopic gastric bypass

BackgroundAnastomotic stenosis, leak, and hemorrhage are common stapler-related complications of laparoscopic Roux-en-Y gastric bypass. In May 2007, we transitioned from a 25-mm diameter, 4.8-mm-height circular stapler to a 25-mm, 3.5-mm-height circular stapler. We hypothesized that the staple height would be associated with a decreased incidence of perioperative complications.MethodsThe records of 360 consecutive patients who had undergone laparoscopic Roux-en-Y gastric bypass from May 1, 2006 to March 31, 2008 were retrospectively abstracted. The National Surgical Quality Improvement Project and Michigan Bariatric Surgery Collaborative databases were used to collect the patient demographics and track complications of laparoscopic Roux-en-Y gastric bypass. Data were collected on the rates of anastomotic stenosis requiring dilation of the gastrojejunostomy, anastomotic leak, hemorrhage requiring transfusion, and wound infection. Patients with a 4.8-mm staple height gastrojejunostomy were compared with those with a 3.5-mm staple height gastrojejunostomy for differences in complications.ResultsThe groups were similar with respect to age, gender, body mass index, hypertension, hyperlipidemia, diabetes, sleep apnea, and surgery duration. In the 4.8- and 3.5-mm staple height groups, 15% and 6.1% required gastrojejunal dilation, respectively (P = .01). A trend was seen toward a decrease in postoperative hemorrhage (5% versus 2.8%) with the shorter staple height. No anastomotic leaks occurred, and the incidence of wound infection (1.7% versus 2.2%) was similar between the 2 groups.ConclusionIn the present study, the use of a 25-mm, 3.5-mm staple height circular stapler was associated with a decreased rate of anastomotic stenosis.     

Role of Intraoperative Esophagogastroenteroscopy in Minimizing Gastrojejunostomy-Related Morbidity: Experience with 2,311 Laparoscopic Gastric Bypasses with Linear Stapler Anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).     

Incidence of Gastrojejunostomy Stricture in Laparoscopic Roux-en-Y Gastric Bypass Using an Autologous Fibrin Sealant

Background

Anastomotic leak at the gastrojejunostomy is a life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Fibrin sealants have been used as topical adjuncts to reduce leaks at the gastrojejunostomy. Our clinical observations suggest that an unintended consequence may be the promotion of anastomotic stricture. We hypothesized that the use of fibrin sealant at the gastrojejunostomy in patients undergoing LRYGB decreases the incidence of anastomotic leak but increases the incidence of clinically significant stricture.

Methods

Following institutional review board approval, medical records of patients undergoing LRYGB by two surgeons at a single institution over a 5-year period were retrospectively reviewed. Preoperative demographics and postoperative complication rates including incidence of gastrojejunostomy leak and endoscopically diagnosed stricture requiring dilation within 1 year of surgery were recorded.

Results

Four hundred twenty-five patients had fibrin sealant routinely applied to their gastrojejunostomy site and 104 did not. Four leaks occurred in the sealant group and two leaks occurred in the control group (p?=?0.2). Of patients who received sealant, 1.6 % needed postoperative blood transfusion compared to those 1.6 % of patient who did not receive sealant (p?=?0.05). There was a significantly increased rate of strictures requiring dilation in the sealant group (11.3 % compared to 4.8 % stricture rate in patients who did not receive sealant, p?=?0.04).

Conclusions

In our experience, the use of fibrin sealant at linear stapled gastrojejunostomy site during LRYGB increases the incidence of clinically significant postoperative stricture and does not reduce the incidence of anastomotic leak.     

Collagen matrix staple line reinforcement in gastric bypass

BackgroundStaple line leaks and bleeding, anastomotic strictures, and marginal ulcers are significant complications of Roux-en-Y gastric bypass (RYGB) for morbid obesity. Reinforcing the staple lines with bovine collagen matrix reinforcement (CMR) might safely decrease the incidence of leaks and bleeding without causing other complications. Our objective was to determine the effect in RYGB of reinforcing the linear and circular gastric staple lines with CMR on the outcomes including abdominal septic events, blood transfusions, and the incidence of stricture and marginal ulceration of the gastrojejunostomy in a private bariatric surgery practice at 2 Surgical Review Committee Center of Excellence community hospitals.MethodsWe performed a retrospective review of prospectively collected data comparing consecutive outcomes of 505 patients undergoing RYGB without CMR from 2005 to 2006 to 568 patients with CMR of the linear and circular gastric staple lines from 2007 to 2009.ResultsThe application of CMR was associated with a significant reduction from 4% to 1% in the incidence of abdominal septic events, including frank staple line leakage, purulent drainage, and abscess. The number of patients needing transfusion showed a trend downward. The frequency of stricture (1%) and marginal ulceration (2%) was unchanged. No gastrogastric fistulas were identified in either group. No evidence of migration of collagen matrix material appeared after CMR. The 90-day mortality rate for each group was .2% and was unrelated to staple line complications.ConclusionThe use of CMR was associated with a significant reduction in the incidence of abdominal septic complications and a trend toward fewer patients needing transfusion. The frequency of stricture and marginal ulceration was unchanged by the use of CMR.     

Clinical results using bioabsorbable staple line reinforcement for circular staplers

Although linear surgical staple line reinforcement has been shown to increase anastomotic tensile strength in animal models and reduce the incidence of staple line bleeding and anastomotic leaks in colorectal surgery, the benefits of staple line reinforcement on circular stapled anastomoses in bariatric surgery remain unreported in the literature. The purpose if this study was to compare the incidence of anastomotic bleeding, leak, and stricture in patients undergoing laparoscopic gastric bypass with circular staple line reinforcements with those with no circular staple line reinforcements. Since May 2006, 138 consecutive patients (Group B) have undergone laparoscopic Roux-en-Y divided gastric bypass with a 25-mm circular stapled gastrojejunal anastomosis using GORE SEAMGUARD bioabsorbable circular staple line reinforcement (CBSG) with a mean follow up of 9 months. The incidence of anastomotic bleeding, leak, and stricture was compared with 255 similar patients (Group A) who underwent surgery before May 2006 without gastrojejunal reinforcement with a mean follow up of 22 months. The rates of anastomotic bleeding, leak, and stricture for Group B versus Group A were 0.7 per cent versus 1.1 per cent (P = 0.64); 0.7 per cent versus 1.9 per cent (P = 0.34); and 0.7 per cent versus 9.3 per cent (P = 0.0005), respectively. The use of CBSG reduced the incidence of anastomotic stricture by 93 per cent and the incidence of a composite end point of all anastomotic complications by 85 per cent. Our results indicate that the use of circular staple line reinforcement at the gastrojejunal anastomosis in patients undergoing laparoscopic gastric bypass significantly decreases the incidence of anastomotic stricture and a composite end point of all anastomotic complications. On this basis, strong consideration should be given to the routine use of CBSG staple line reinforcement in patients undergoing laparoscopic divided gastric bypass with a circular stapled gastrojejunal anastomosis.     

Short-Term Outcomes of Sleeve Gastrectomy for Morbid Obesity: Does Staple Line Reinforcement Matter?

Background

Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients.

Methods

We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n?=?186), whereas all patients treated afterward did (n?=?332).

Results

The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82 % female; mean preoperative body mass index, 44 kg/m²) were 67 % (79 % follow-up rate) at 6 months postoperatively, 81 % (64 %) at 1 year, and 84 % (30 %) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p?=?0.045) and one case of bleeding.

Conclusions

LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.     

Preventing Staple-Line Leak in Sleeve Gastrectomy: Reinforcement with Bovine Pericardium vs Oversewing

One of the most serious, potentially life-threatening complications of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Oversewing the LSG staple line vs buttressing it with bovine pericardial strips (BPS) to reduce perioperative bleeding and postoperative gastric leak was evaluated. From 2006 through 2011, 160 patients underwent LSG with suturing as the only staple-line reinforcement (Group A). From March 2010 through August 2012, 84 LSG patients had BPS incorporated into their last two stapler firings (Group B). Staple lines were evaluated perioperatively for bleeding, and patients were monitored for indications of staple-line leaks (peritonitis, abnormal output from the drain). In preoperative Group A and B, there were 117 (73.1 %) vs 56 (66.7 %) females; mean age, 35.2 years (18.0–68.0) vs 33.8 years (15.0–64.0); mean body mass index (BMI, kilograms per square meter), 42.5 (27.0–76.0) vs 42.0 (30.0–58.0). Three months after surgery, mean BMI for Group A was 37.3 (?5.9); Group B, 35.2 (?7.3); at 6 months, 32.7 (?10.8) and 31.5 (?11.3; p?<?0.001). Although there was no significant difference in perioperative blood loss, oversewn staple lines in Group A often required electrocautery to stanch bleeding; this was not required for Group B. In Group A, 15 patients (9.4 %) developed complications; in Group B, five (6.0 %; p?=?0.46). Gastric fistula, verified by barium swallow, occurred in eight Group A patients (5.0 %); in Group B, one (1.2 %; p?=?0.17). Relative to oversewing, staple-line buttressing with bovine pericardium was readily accomplished, safe, and associated with a lower staple-line leak rate.     

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift

BackgroundDuring the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals.MethodsWe reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded.ResultsThere were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient.ConclusionEIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.     

Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review

ObjectiveThe study compared laparoscopic sleeve gastrectomy (LSG) staple-line leak rates of 4 prevalent surgical options: no reinforcement, oversewing, nonabsorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM).BackgroundLSG is a multipurpose bariatric/metabolic procedure with effectiveness proven through the intermediate term. Staple-line leak is a severe complication of LSG for which no definitive method of prevention has been identified.MethodsThe systematic review study design was employed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement screening guidelines. Inclusion criteria centered on variables potentially relevant to LSG leak: leak rate, age, gender, calibrating bougie size, distance between pylorus and gastric transection line, overall complication rate, and mortality. Analysis of variance models were used to explore differences in select demographic and surgical technique variables characterizing each reinforcement group. An omnibus χ² test followed by independent Fisher’s exact tests were used to compare leak rates.ResultsThere were 659 articles identified; 41 duplicates removed. Of 618 remaining articles, 324 did not meet inclusion criteria. Of the 294 remaining articles, 206 were eliminated (kin studies, those not reporting staple-line or leak incidence, those reporting discontinued products). There were 88 papers included in the analysis. Statistically significant differences were found between groups across demographic and surgical variables studied (p<0.001). There were 191 leaks in 8,920 patients; overall leak rate 2.1%. Leak rates ranged from 1.09% (APM) to 3.3% (BPS); APM leak rate was significantly lower than other groups (p< 0.05).ConclusionSystematic review of 88 included studies representing 8,920 patients found that the leak rate in LSG was significantly lower using APM staple-line reinforcement than oversewing, BPS reinforcement, or no reinforcement.     

Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: A multicenter study

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG.MethodsA total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m². The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients’ characteristics with complications.ResultsA total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P<.01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P = .02). Only diabetes was a risk-factor for a leak (P< .01).ConclusionSLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type II diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG.     

The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks

BackgroundLaparoscopic sleeve gastrectomy (LSG) is thought to be a simpler and safer operation compared with malabsorptive operations that include an enteric anastomosis. Leakage along the staple line at the gastroesophageal junction (GEJ) is difficult to treat and is a known complication of sleeve gastrectomy. Nonsurgical treatment methods often fail to heal the leaks and patients often require conversion to other procedures for definitive treatment. We report our experience with conversion to Roux-en-Y anastomosis over the leak site as a treatment option, comparing patients who had early treatment to late intervention. The purpose of the study is to stress the medical and social benefits of early surgical reintervention with conversion to Roux-en-Y anastomosis over the leak site.MethodsSix patients underwent Roux limb placement over the leak site. Four of the patients had delayed surgery (group A), and the other 2 had early intervention (group B).ResultsPatients in group A had a median increase of all medical cost by 500%, whereas the 2 patients who underwent early intervention (group B) had an increase by 200%. The mean time until complete recovery (removal of all drains, adequate oral intake, and return to normal daily activity) in group A was 131.25 days (range 99–165) versus 38 days (range 28–48) in group B.ConclusionsRoux-en-Y gastrojejunostomy over the leak site is an effective technique to treat refractory staple line leakage and can be adopted as early treatment in selected patients after stabilization, thereby reducing the cost and length of hospital stays.     

The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery

BackgroundThe use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures.MethodsWe treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded.ResultsAll but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)—2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently.ConclusionOnly 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.     

Staple Line Reinforcement Methods in Laparoscopic Sleeve Gastrectomy: Comparison of Burst Pressures and Leaks

Background and Objectives:

Laparoscopic sleeve gastrectomy is a technically simple and popular bariatric operation with acceptable results. However, leaks can occur in long staple lines, for which various reinforcement methods are used. We compared nonreinforced stapling in laparoscopic sleeve gastrectomy with 3 staple line reinforcement methods: suturing, absorbable buttressing material, and fibrin glue.

Methods:

From March 1 until September 30, 2014, 118 patients with body mass index >40 kg/m² underwent sleeve gastrectomy and were enrolled in 4 groups, depending on the type of reinforcement used. The resected stomach specimens were treated with the same methods of reinforcement as used in the surgeries in the corresponding patients and then insufflated until a burst occurred. The burst pressures of the resected stomach specimens and adverse postoperative events were recorded.

Results:

Five postoperative leaks occurred in the reinforcement groups (fibrin glue, 2; absorbable buttresses, 2; sutures, 1); no leaks were evident in the no-reinforcement group. Suturing afforded the highest burst pressure and took the longest to perform of the methods. There was no correlation between the leaks and burst pressures. All of the leaks occurred in the proximal fundus in the resected stomach specimens and in the affected patients.

Discussion:

Although most surgeons use additional reinforcement on long staple lines in sleeve gastrectomy, there is no consensus about its necessity. We did not show any benefit of such reinforcement methods over proper stapling technique alone.

Conclusion:

Laparoscopic sleeve gastrectomy without staple line reinforcement is safe and avoids additional costs for reinforcement materials.     

Low Incidence of Postoperative Leaks When Using Small-Diameter Calibrated Bougies During Laparoscopic Sleeve Gastrectomy: A Retrospective Cohort Study

Background

Laparoscopic sleeve gastrectomy (LSG) is a well-established bariatric procedure. A staple line leak is a recognized complication of LSG. Bougie size has been suggested to impact leak rates. In this study, we evaluate the impact of using 32–34F bougie sizes with LSG on early postoperative outcomes including staple line leaks within our practice.

Methods

This is a retrospective cohort analysis of a prospectively maintained database of all LSG procedures performed between January 2012 and December 2018 at a single medical center. Data collected and analyzed included bougie size, postoperative leak rate, need for re-operation, 12-month excess weight loss, and 30-day morbidity and mortality.

Results

During the study period, 3153 patients underwent LSG, of whom 1977 (62.7%) were female. Mean age and body mass index (BMI) were 42.9 ± 12.2 years (range 15–76 years) and 42.4 ± 5.2 kg/m² (range 27–73), respectively. No intraoperative complications or mortality occurred. There was one case of perioperative mortality due to bleeding (0.03%). Early postoperative adverse events occurred in 131 patients (4.1%): 17 leaks (0.5%), 75 bleeds (2.4%), and 39 (1.2%) other.

Conclusion

The use of smaller-sized (32–34F) bougies had no impact on staple line leaks in the hands of experienced bariatric surgeons at a high-volume center.

     

The Use of Staple-Line Reinforcement During Laparoscopic Gastric Bypass

Divided linear staple-lines are a mainstay of gastrointestinal surgery, and in particular, bariatric surgery. Staple-line failure, although uncommon, can result in significant morbidity and even mortality. Staple-line buttressing has been developed to improve staple-line strength, decrease bleeding and minimize the risk of leak. Many different products are currently available. However, most have not been proven in clinical trials. Bovine pericardial strips (BPS) are a buttressing material that fits onto the stapler device and gets "stapled" onto the tissue when the device is fired. The strips add thickness and potentially strength to the staple-line. Animal research has shown that staple-lines incorporated with BPS had higher burst pressures than those without. Human experience has suggested that BPS decreased the risk of acute staple-line failures in laparoscopic Roux-en-Y gastric bypass surgery. This report reviews the clinical and research experience with this product.     

Feasibility of Sleeve Gastrectomy as a Revision Operation for Failed Silastic Ring Vertical Gastroplasty

Background  Restrictive bariatric operations are efficient with low morbidity but entail high rate of failure on follow up of several years. We present our experience in laparoscopic revision of patients who previously underwent silastic ring vertical gastroplasty (SRVG) into laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB). Methods  Data on 12 patients who underwent revisional operations after SRVG was prospectively collected. Six patients underwent LRYGB and six patients underwent LSG. The pathogeneses for failures of SRVG were disruption of staple line, enlargement of gastric pouch, and opening of the ring. Results  The average age and body mass index (BMI) were 39 and 43, respectively, in the LSG group versus average age and BMI of 39 and 45, respectively, in the LRYGP group (p = 0.45 and p = 0.35, respectively). The average operative time were 206 and 368 min in the LSG and LRYGB groups, respectively (p < 0.01). There were five postoperative complications among LSG group versus two complications in LRYGB group (p < 0.01). Patients who underwent LSG suffered from the following complications: staple line leak in two patients, intra-abdominal hematoma in one patient, intra-abdominal collection in one patient, and gastric outlet obstruction in one patient. Anastomotic leak and wound infection were the complications seen among patients underwent LRYGB. All complications were treated conservatively without necessitating immediate reoperations. Follow-up has shown adequate reduction of body weight and improved quality of life in both groups of patients. Conclusions  Revisional bariatric operation is a challenging laparoscopic procedure with higher morbidity compared to primary bariatric operations. Morbidity of LSG compared to LRYGB as a revisional procedure for SRVG is significantly higher.