Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Absorbable Monofilament,Barbed Suture,Fibrin Glue,or Nothing? Results of a Prospective Randomized Study

Background

Laparoscopic sleeve gastrectomy (LSG) is associated with serious complications, such as staple line (SL) leaks and bleeding. In order to prevent the occurrence of these complications, surgeons have advocated the need to strengthen the staple line. The aim of this randomized controlled study was to compare the efficacy of three different ways of strengthening of the SL in LSG in preventing surgical post-operative complications.

Methods

Between April 2012 and December 2014, 600 patients (pts) scheduled for LSG were prospectively randomized into groups without SL reinforcement (group A) or with SL reinforcement including fibrin glue coverage (group B), or oversewn SL with imbricating absorbable (Monocryl?; group C) or barbed (V lock®) running suture (group D). Primary endpoints were post-operative leaks, bleeding, and stenosis, while secondary outcomes consisted of the time to perform the staple line reinforcement (SLR) and total operative time.

Results

Mean SLR operative time was lower for group B (3.4?±?1.3 min) compared with that for groups C (26.8?±?8.5 min) and D (21.1?±?8.4 min) (p?<?0.0001). Mean total operative time was 100.7?±?16.4 min (group A), 104.4?±?22.1 min (group B), 126.2?±?18.9 min (group C), and 124.6?±?22.8 (group D) (p?<?0.0001). Post-operative leaks, bleeding, and stenosis were recorded in 14 pts (2.3 %), 5 pts (0.8 %), and 7 pts (1.1 %), respectively, without statistical difference between the groups.

Conclusion

Our study suggests that SLR during LSG, with an imbricating or non-imbricating running suture or with fibrin glue, is an unrewarding surgical act with the sole effect of prolonging the operative time.

     

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.     

Lower reoperation rates with the use of fibrin sealant versus tacks for mesh fixation

Background

Groin hernia repair may be associated with long-term complications such as chronic pain, believed to result from damage to regional nerves by tissue penetrating mesh fixation. Studies have shown that mesh fixation with fibrin sealant reduces the risk of these long-term complications, but data on recurrence and reoperation rates after the use of fibrin sealant compared with tacks are not available. This study aimed to determine whether fibrin sealant is a safe and feasible alternative to tacks with regard to reoperation rates after laparoscopic groin hernia repair.

Methods

The current study compared reoperation rates after laparoscopic groin hernia repair between fibrin sealant and tacks used for mesh fixation. The study used data collected prospectively from The National Danish Hernia Database and analyzed 8,314 laparoscopic groin hernia repairs for reoperation rates. Mesh fixation was performed with fibrin sealant (n = 784) or tacks (n = 7,530).

Results

The findings showed a significantly lower reoperation rate for the fibrin sealant than for the tacks (0.89 vs 2.94 %, p = 0.031). The median follow-up period was 17 months (range, 0–44 months) for the fibrin sealant group and 21 months (range, 0–44 months) for the tacks group.

Conclusions

Fibrin sealant was superior to tacks for mesh fixation in laparoscopic groin hernia repair with regard to reoperation rates. The study could not differentiate between different hernia defect sizes, and future studies should therefore explore whether the superior effect of fibrin sealant applies for all hernia types and sizes.     

Reinforcing the Staple Line During Laparoscopic Sleeve Gastrectomy: Prospective Randomized Clinical Study Comparing Three Different Techniques

Background

Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (LSG). In order to reduce these complications, the staple line can be reinforced by absorbable sutures or by the use of glycolide trimethylene carbonate copolymer onto the linear stapler (Gore Seamguard®; W.L. Gore &; Associates, Inc, Flagstaff, AZ). To our knowledge, there are no randomized studies showing the utility of staple line reinforcement during LSG. The purpose of this study was to randomly compare three techniques in LSG: no staple line reinforcement (group 1), buttressing of the staple line with Gore Seamguard® (group 2), and staple line suturing (group 3).

Methods

Between January 2008 and February 2009, 75 patients were prospectively and randomly enrolled in the three different techniques of handling the staple line during LSG. The patient groups were similar (NS).

Results

Mean operative time to perform the stomach sectioning was 15.9?±?5.9 min (group 1), 20.8?±?8.1 min (group 2), and 30.8?±?10.1 min (group 3) (p?p?=?0.02). Mean blood loss during stomach sectioning was 19.5?±?21.3 mL (group 1), 3.6?±?4.7 mL (group 2), and 16.7?±?23.5 mL (group 3) (p?p?=?0.03). Mean number of stapler cartridges used was 5.6?±?0.7 (group 1), 5.7?±?0.7 (group 2), and 5.8?±?0.6 (group 3) (NS). Postoperative leak affected one patient (group 1), two patients (group 2), and one patient (group 3) (NS). Mean hospital stay was 3.6?±?1.4 days (group 1), 3.9?±?1.5 days (group 2), and 2.8?±?0.8 days (group 3) (p?=?0.01).

Conclusions

In LSG, buttressing the staple line with Gore Seamguard® statistically reduces blood loss during stomach sectioning as well as overall blood loss. No staple line reinforcement statistically decreases the time to perform stomach sectioning and the total operative time. No significant difference is evidenced in terms of postoperative leak between the three techniques of LSG.

     

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

Background

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

Methods

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

Results

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6?±?9.2 (range, 28–64)?years. Mean preoperative body mass index was 47.2?±?6.6 (range, 40–66)?kg/m2. Mean time for SLR was longer in group A (14.2?±?4.2 (range, 8–18)?minutes) compared with group B (2.4?±?1.8 (range, 1–4)?minutes) and group C (4.4?±?1.6 (range, 3–6) minutes; P?Conclusions SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.     

Hemostatic efficacy of latest-generation fibrin sealant after hepatic resection: a randomized controlled clinical study

Purpose

This randomized, controlled, single-blinded multicenter study evaluated the efficacy of latest-generation fibrin sealant containing synthetic aprotinin as fibrinolysis inhibitor as supportive treatment for hemostasis after elective partial hepatectomy.

Methods

Adult subjects undergoing resection of at least one liver segment were assigned to treatment with fibrin sealant or manual compression with a surgical gauze swab if persistent oozing necessitated additional hemostatic measures after primary control of arterial and venous bleeding. The primary outcome measure was the proportion of subjects with intraoperative hemostasis at 4 min after start of randomized treatment application. Secondary efficacy outcome measures included intraoperative hemostasis at 6, 8, and 10 min, intra- and postoperative rebleedings, transfusion requirements, and drainage volume.

Results

Seventy subjects were randomized. Hemostasis at 4 min was achieved in 29/35 (82.9 %) fibrin sealant subjects compared with 13/35 (37.1 %) control subjects (p?p?p?=?0.028), and 10 min (p?=?0.017). The number of rebleedings was low in both study arms. Transfusion requirements and 48-h drainage volumes were similar between the study arms. No adverse events related to study treatment were reported.

Conclusions

Fibrin sealant was shown to be safe and superior to manual compression in the control of parenchymal bleeding after hepatic resection. The use of synthetic aprotinin as fibrinolysis inhibitor further improves the safety margin of fibrin sealant by eliminating the risk of transmission of bovine spongiform encephalopathy and other bovine pathogens.     

Comparison Between Stable Line Reinforcement by Barbed Suture and Non-reinforcement in Sleeve Gastrectomy: a Randomized Prospective Controlled Study

Introduction

Laparoscopic sleeve gastrectomy (LSG) is now a popular bariatric procedure worldwide with rising prevalence over the last decade. Staple line leak and bleeding are the most dangerous complications of LSG. Staple line reinforcement (SLR) by oversewing the staple line was suggested to reduce the incidence of leak and bleeding. We designed a randomized controlled prospective study to investigate the value of SLR by invaginating the whole staple line using unidirectional absorbable 3/0 V-Loc 180 sutures (Covidien, Mansfield, MA, USA) to no SLR in LSG.

Patients and Methods

Nine hundred and twenty patients undergoing LSG between March 2016 and March 2017 were included in the study; they were prospectively randomized into two groups: A and B, each of 460 patients. In group A, the entire staple line was invaginated with continuous seromuscular suturing using 3/0 V-Loc 180 suture (Covidien, Mansfield, MA, USA), and in group B, no reinforcement was done. The patients were selected according to National Institute of Health (NIH) guidelines. All procedures were performed by the same team of experienced bariatric surgeons. Patients were followed up for 6 weeks after surgery for occurrence of complications.

Results

The two groups were matched considering the demographic data. Operative time was significantly longer in group A (P?=?0.001), with mean operative time in group A was 69 min, while that in Group B was 50.8 min. Leak occurred in eight cases (1.7%) in group B and none (0%) in group A; leak was significantly lower in group A (P?=?0.008). Bleeding occurred in two patients (0.4%) in group A and in seven (1.5%) in group B (P?=?0.178), with no statistically significant difference between both groups as regards bleeding.

Conclusion

Comparing SLR by invaginating the whole staple line using unidirectional absorbable 3/0 V-Loc 180 sutures (Covidien, Mansfield, MA, USA) to no SLR in a relatively large cohort of patients undergoing LSG, in a randomized controlled prospective study, has proved statistically significant value for SLR by invaginating sutures.

     

The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial

Background

Published interim results have shown that fibrin sealant (Tissucol^®/Tisseel^® Baxter AG, Vienna, Austria) may be effective in preventing anastomotic leaks and internal hernias following laparoscopic Roux-en-Y gastric bypass (LRYGBP). We report the final results of a multicenter, randomized clinical trial evaluating the use of fibrin sealant in LRYGBP.

Methods

Between January 2004 and December 2005, 340 patients aged 21–65 years with a body mass index (BMI) of 40–59 kg/m² undergoing LRYGBP were randomized (1:1) to two treatment groups: fibrin sealant group (applied to gastrojejunal and jejunojejunal anastomoses and over mesenteric openings), and control group (no fibrin sealant; suture of the mesenteric openings). Operative time, early and late complications, reinterventions, time to oral diet initiation, and length of stay were assessed.

Results

Overall, 320 patients were included into the study: 160 in the control group and 160 in the fibrin sealant group. All patients completed follow-up assessments at 6 and 12 months, and 60.9% completed assessments at 24 months. There were no significant differences between groups with respect to demographics, operative time, oral diet initiation, hospital stay, and BMI reduction at 6, 12, and 24 months. The incidence of anastomotic leak was numerically, but not significantly, greater in the control group. The overall reintervention rate for specific early complications (<30 days) was significantly higher in the control group (p = 0.016). No deaths or conversions to open laparotomy occurred.

Conclusion

The use of fibrin sealant in laparoscopic RYGBP may be beneficial in reducing the reintervention rate for major perioperative (<30 days) complications. Larger studies are needed.     

Fibrin sealant for mesh fixation in laparoscopic umbilical hernia repair: 1-year results of a randomized controlled double-blinded study

Purpose

Fibrin sealant for mesh fixation has significant positive effects on early outcome after laparoscopic ventral hernia repair (LVHR) compared with titanium tacks. Whether fibrin sealant fixation also results in better long-term outcome is unknown.

Methods

We performed a randomized controlled trial including patients with umbilical hernia defects from 1.5 to 5 cm at three Danish hernia centres. We used a 12 cm circular mesh. Participants were randomized to fibrin sealant or titanium tack fixation. Patients were seen in the outpatient clinic at 1 and 12 months follow-up.

Results

Forty patients were included of whom 34 were available for intention to treat analysis after 1 year. There were no significant differences in pain, discomfort, fatigue, satisfaction or quality of life between the two groups at the 1-year follow-up. Five patients (26 %) in the fibrin sealant group and one (6 %) in the tack group were diagnosed with a recurrence at the 1-year follow-up (p = 0.182) (overall recurrence rate 17 %). Hernia defects in patients with recurrence were significantly larger than in those without recurrence (median 4.0 vs. 2.8 cm, p = 0.009).

Conclusion

Patients with larger hernia defects and fibrin sealant mesh fixation had higher recurrence rates than expected, although the study was not powered for assessment of recurrence. There was no significant difference between groups in any parameters after the 1-year follow-up. The beneficial effects of mesh fixation with fibrin sealant on early outcome warrant further studies on optimization of the surgical technique to prevent recurrence.     

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.     

Early Post-operative Complications: Incidence, Management, and Impact on Length of Hospital Stay. A Retrospective Comparison Between Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

Methods

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

Results

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p?=?0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p?=?0.042). Mean BMI was significantly higher in the complicated LSG group (54.2?±?8.3) vs. complicated LRYGB group (46.8?±?5.7; p?=?0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p?=?0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p?=?0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p?=?0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

Conclusions

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.     

Primary Sleeve Gastrectomy Compared to Sleeve Gastrectomy as Revisional Surgery: Weight Loss and Complications at Intermediate Follow-up

Introduction

The laparoscopic adjustable gastric band (LAGB) can be revised to sleeve gastrectomy (LSG) for various reasons. Data are limited on the safety and efficacy of single-stage removal of LAGB and creation of LSG.

Methods

A retrospective review of cases was performed from 2010 to 2013. From the primary LSG group, a control group was matched in a 2:1 ratio.

Results

Thirty-two patients underwent single-stage revision from LAGB to LSG, with a control group of 64. The most common indication for revision was insufficient weight loss (62.5 %). Operative time for revision and control groups was 134 and 92 min, respectively (p?p?=?0.02). Overall, the 30-day complication rate for revision and control patients was 14.71 and 6.25 %, respectively (p?=?0.20). There were no leaks, one stricture (3.13 %) in the revision group, and one reoperation for bleeding in the control group (1.56 %). For patients with BMI >30 at surgery, change in BMI at 12 months for revision and control was 8.77 and 11.58, respectively (p?=?0.02).

Conclusion

Single-stage revision can be performed safely, with minimal increases in hospital stay and 30-day complications. Weight loss is greater in those who undergo primary LSG compared to those who undergo LSG as revision.     

Single-stage revision from gastric band to gastric bypass or sleeve gastrectomy: 6- and 12-month outcomes

Background

Laparoscopic adjustable gastric banding (LAGB) is increasingly requiring revisional surgery for complications and failures. Removal of the band and conversion to either laparoscopic Roux-en-y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) is feasible as a single-stage procedure. The objective of this study is to compare the safety and efficacy of single-stage revision from LAGB to either LRYGB or LSG at 6 and 12 months postoperatively.

Methods

Retrospective analysis was performed on patients undergoing single-stage revision between 2009 and 2014 at a single academic medical center. Patients were reassessed for weight loss and complications at 6 and 12 months postoperatively.

Results

Thirty-two patients underwent single-stage revision to LRYGB, and 72 to LSG. Preoperative BMIs were similar between the two groups (p = 0.27). Median length of stay for LRYGB was 3 days versus 2 for LSG (p = 0.14). Four patients in the LRYGB group required reoperation within 30 days, and two patients in the LSG group required reoperation within 30 days (p = 0.15). There was no difference in ER visits (p = 0.24) or readmission rates (p = 0.80) within 30 days of operation. Six delayed complications were seen in the LSG group with three requiring intervention. At 6 months postoperatively, percent excess weight loss (%EWL) was 50.20 for LRYGB and 30.64 for LSG (p = 0.056). At 12 months, %EWL was 51.19 for LRYGB and 34.89 for LSG (p = 0.31). There was no difference in diabetes or hypertension medication reduction at 12 months between LRYGB and LSG (p > 0.07).

Conclusion

Single-stage revision from LAGB to LRYGB or LSG is technically feasible, but not without complications. The complications in the bypass group were more severe. There was no difference in readmission or reoperation rates, weight loss or comorbidity reduction. Revision to LRYGB trended toward higher rate and greater severity of complications with equivalent weight loss and comorbidity reduction.

     

Staple Line Bleeding in Sleeve Gastrectomy—a Simple and Cost-Effective Solution

Background

Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding.

Methods

In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients.

Results

Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m²), gender distribution (female:male?=?20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p?<?0.05), incurred less intraoperative blood loss (p?<?0.01) and had quicker operating times (median 66 vs 80 min, p?<?0.05). There was no difference in morbidity or mortality in both groups.

Conclusion

Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times.

     

Sleeve Gastrectomy Severe Complications: Is It Always a Reasonable Surgical Option?

Background

Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications.

Methods

A retrospective database analysis was done to study LSG staple line complications in a tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure.

Results

Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (n?=?1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p?=?0.003). Median time to cure was 310 days (9–546 days).

Conclusions

LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.     

Influence of fibrin sealant in preventing postoperative seroma and normalizing the abdominal wall after laparoscopic repair of ventral hernia

Background

Seroma after laparoscopic ventral hernia repair (LVHR) has been related to certain complications of the technique, such as recurrences and postoperative pain. The aim of this study was to assess whether percutaneous application of fibrin sealant in the hernia sac after LVHR reduces the incidence and volume of the postoperative seroma, and to analyze whether the percentage of patients achieving complete normalization of the abdominal wall increases.

Methods

Prospective and comparative study. Patients were distributed into 2 control–case groups. Group 1 comprised patients submitted to LVHR using the double crown technique and a compressing bandage as the only method for prevent seroma. Group 2 comprised patients admitted to LVHR using the same technique together with percutaneous injection of fibrin sealant in the sac, and later applying the same bandage. Patients were examined clinically and radiologically at 7 days, 1 month, and 3 months after surgery.

Results

Twenty-five patients were included in each group. There were significant differences in the incidence of seroma by the day 7 after surgery (92 % in group 1 vs. 64 % in group 2, p = 0.017) and by 1 month (72 % in group 1 vs. 28 % in group 2, p = 0.002). The difference was also significant regarding the achievement of normalization of the abdominal wall by day 7 (24 % in group 1 vs. 52 % in group 2, p = 0.041) and by month 1 (64 % in group 1 vs. 88 % in group 2, p = 0.047) after operation. Volume of seroma was larger among patients of group 1 after the week (p = 0.002) and 1 month after operation (p = 0.001).

Conclusions

Fibrin sealant application after LVHR reduces the incidence and volume of the seroma 7 days and 1 month after surgery. The treated patients obtain a larger normalization of the abdominal wall 1 week and 1 month after the operation.     

Buttressing the Staple Line: A Randomized Comparison Between Staple-Line Reinforcement Versus No Reinforcement During Sleeve Gastrectomy

Bariatric surgery is recommended for Indian patients with body mass index (BMI) >32.5 kg/m² with at least one comorbidity and >37.5 kg/m² without a comorbidity. In laparoscopic sleeve gastrectomy, bleeding and leakage from the staple line are common post-operative events. Peri-Strips Dry® with Veritas® (PSD-V) is used in staple-line reinforcement. This was a single-investigator, multicenter, randomized study of 100 patients undergoing standard sleeve gastrectomy with a 34 or 36 French bougie. Patients were randomized 1:1 to PSD-V or control groups; no buttress material was used in the control group. The primary objective was to assess complication rates (any staple-line bleed or leak from the intra-operative visit through day 30) associated with sleeve gastrectomy. Surgical time (from first incision to closure of last incision) and the number of clips and/or sutures used to control bleeding were also assessed. Fewer staple-line bleeds were observed in the PSD-V group than the control group (23/51 [45.1 %] vs 39/49 [79.6 %] patients; p?=?0.0005), and the bleeding was of a lower severity (p?=?0.0002). No staple-line leaks were observed. Surgical time was shorter in patients who received PSD-V (58.8 vs 72.8 min; p?=?0.0153), and fewer patients required hemostatic clips and/or sutures (10/51 [19.6 %] vs 33/49 [67.3 %] patients; p?相似文献   

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Evaluating the impact of the antrum size following laparoscopic sleeve gastrectomy: a randomized multicenter study

BackgroundThe effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) remains discordant and highly related to the surgical technique. GERD and weight regain are probably understudied by prospective clinical studies depending on different technical factors.ObjectivesThe purpose of this article is to evaluate the effect of extent to which the antrum is resected on GERD following LSG but also on early complications and short-term weight loss results.SettingUniversity Hospital, France.MethodsPatients were randomly assigned in group A (172 patients), LSG with antral resection, or group B (174 patients), LSG with antral preservation. The baseline characteristics collected were demographic characteristics and anthropometric data (age, sex, body mass index), presence of GERD clinical characteristics, ± pH-metry, postoperative complications, or gastrin level.ResultsA total of 279 patients underwent LSG and they were included in the final analysis. The GERD analyzed at 3 months postoperatively by pH-metry was observed for 57.8% in group A and for 52.4% of patients in group B (P = .4819). There was no statistically significant difference (P = .3755) between the 2 groups at 1 year after surgery (group A, 49.5% versus group B, 43.6%). The gastrin serum level was analyzed 1 year after surgery for a total of 107 patients. For group A, the mean gastrin level was 97.4 ± 85.9 pg/mL, which was inferior compared with group B (150.6 ± 152.4 pg/mL) with no statistical difference (P = .067). The recorded excess weight loss for group A was 79.67% (± 28.88) with no statistically significant difference with group B 74.46% (± 36.61) (P = .3678). The mortality rate was nil. We recorded 5 cases of staple line leakage (3 in group A and 2 in group B); 11 patients presented bleeding (3 in group A and 8 group B), and 4 patients presented with gastric stenosis (2 in group A and 2 in group B).ConclusionsThe antrum preservation has no significant difference in terms of reflux, weight loss, or complications at 3 or 12 months following LSG. The only significant difference was achieved for nausea and vomiting symptoms, which were more significant for the antrum resection group. Further clinical trials with newer procedures will indicate the factors that can diminish the reflux following LSG. Furthermore, the conservation of a large part of the antrum may be helpful to convert the sleeve to another bariatric procedure (transit bipartition).