Technical details of laparoscopic sleeve gastrectomy with attention to staple line leak and hemorrhage: discussion of 3,031 consecutive cases
DOI:
https://doi.org/10.18203/2349-2902.isj20253445Keywords:
Laparoscopic sleeve gastrectomy, Staple line leak, Bariatric surgery, Surgical technique, Complication prevention, Sleeve gastrectomy outcomesAbstract
Background: Laparoscopic sleeve gastrectomy continues to rise as an effective surgical procedure for weight loss in obese patients. With that, gastric staple line leak and hemorrhage remain the most serious complications and occur in up to 3% of all cases. Each complication is associated with a high degree of morbidity and mortality for the patient as well as substantial cost of care for institutions and payers. Techniques to minimize the risk of sleeve gastrectomy leak and hemorrhage have been published although no universally agreed upon set of techniques exists. This report updates a single-surgeon experience with an approach to sleeve leak and hemorrhage prevention over 10 years.
Methods: 3,031 consecutive sleeve gastrectomy cases between 2012 and 2021 were reviewed retrospectively. Patient characteristics, incidence of leaks and hemorrhage, and percent body weight loss at 6 months were reported for each year. Conceptual and technical changes aimed towards leak and hemorrhage reduction are presented.
Results: With the implementation of the described techniques of sleeve gastrectomy, the rate of sleeve leaks fell from 3.8% in 2012 to 0% in 2015 through 2021, and hemorrhage fell from 1.3% in 2012 to 0.1% in 2018 through 2021. Weight loss remained consistent, as depicted by 6-month change in body weight and percent excess BMI lost.
Conclusion: In this single-surgeon experience, sleeve gastrectomy leak rate fell to 0.0% and staple line hemorrhage rate fell to 0.1% with the implementation of specific technical modifications in the procedure, spanning over 3,031 consecutive cases.
Metrics
References
Clapp B, Ponce J, DeMaria E, Ghanem O, Hutter M, Kothari S, et al. American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Rel Dis. 2022;18(9):1134-40. DOI: https://doi.org/10.1016/j.soard.2022.06.284
Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surgery for Obesity and Related Diseases. 2016;12(4):750-6. DOI: https://doi.org/10.1016/j.soard.2016.01.022
Updated position statement on sleeve gastrectomy as a bariatric procedure. Surgery for Obesity and Related Diseases. 2012;8(3):21-6. DOI: https://doi.org/10.1016/j.soard.2012.02.001
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26(6):1509-15. DOI: https://doi.org/10.1007/s00464-011-2085-3
Mocanu V, Dang J, Ladak F, Switzer N, Birch DW, Karmali S. Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry. Surgery for Obesity and Related Diseases. 2019;15(10):1675-81. DOI: https://doi.org/10.1016/j.soard.2019.07.017
Bransen J, Gilissen LPL, van Rutte PWJ, Nienhuijs SW. Costs of Leaks and Bleeding After Sleeve Gastrectomies. Obes Surg. 2015;25(10):1767-71. DOI: https://doi.org/10.1007/s11695-015-1584-z
Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical Strategies That May Decrease Leak After Laparoscopic Sleeve Gastrectomy. Ann Surg. 2013;257(2):231-7. DOI: https://doi.org/10.1097/SLA.0b013e31826cc714
Rached AA. Gastric leaks post sleeve gastrectomy: Review of its prevention and management. World J Gastroenterol. 2014;20(38):13904. DOI: https://doi.org/10.3748/wjg.v20.i38.13904
Uccelli M, Targa S, Cesana GC, Oldani A, Ciccarese F, Giorgi R, et al. Use of fibrin glue in bariatric surgery: analysis of complications after laparoscopic sleeve gastrectomy on 450 consecutive patients. Updates Surg. 2021;73(1):305-11. DOI: https://doi.org/10.1007/s13304-020-00865-9
Alimi Y, Lofthus A, Merle C, Vigiola Cruz M, Metchik A, Pardo I, et al. Decreased Leak Rate and Need for Reintervention with Use of Closed Suction Calibration System: a Bariatric Surgery Quality Improvement Project. Obes Surg. 2021;31(12):5237-42. DOI: https://doi.org/10.1007/s11695-021-05682-6
Warner DL, Sasse KC. Technical Details of Laparoscopic Sleeve Gastrectomy Leading to Lowered Leak Rate: Discussion of 1070 Consecutive Cases. Minim Invasive Surg. 2017;2017:1-7. DOI: https://doi.org/10.1155/2017/4367059
Berger ER, Clements RH, Morton JM, Huffman KM, Wolfe BM, Nguyen NT,et al. The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies. Ann Surg. 2016;264(3):464-73. DOI: https://doi.org/10.1097/SLA.0000000000001851
al Zoubi M, Khidir N, Bashah M. Challenges in the Diagnosis of Leak After Sleeve Gastrectomy: Clinical Presentation, Laboratory, and Radiological Findings. Obes Surg. 2021;31(2):612-6. DOI: https://doi.org/10.1007/s11695-020-05008-y
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):18. DOI: https://doi.org/10.4103/jmas.JMAS_271_17
Perez M, Brunaud L, Kedaifa S, Guillotin C, Gerardin A, Quilliot D, et al. Does Anatomy Explain the Origin of a Leak after Sleeve Gastrectomy. Obes Surg. 2014;24(10):1717-23. DOI: https://doi.org/10.1007/s11695-014-1256-4
Gagnière J, Slim K, Launay-Savary MV, Raspado O, Flamein R, Chipponi J. Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity. J Visc Surg. 2011;148(3):205-9. DOI: https://doi.org/10.1016/j.jviscsurg.2011.05.004
Dhar VK, Hanseman DJ, Watkins BM, Paquette IM, Shah SA, Thompson JR. What matters after sleeve gastrectomy: patient characteristics or surgical technique? Surgery. 2018;163(3):571-7. DOI: https://doi.org/10.1016/j.surg.2017.09.052
Mocanu V, Marcil G, Dang JT, Birch DW, Switzer NJ, Karmali S. Preoperative weight loss is linked to improved mortality and leaks following elective bariatric surgery: an analysis of 548,597 patients from 2015–2018. Surgery for Obesity and Related Diseases. 2021;17(11):1846-53. DOI: https://doi.org/10.1016/j.soard.2021.06.021
Björklund P, Lönroth H, Fändriks L. Manometry of the Upper Gut Following Roux-en-Y Gastric Bypass Indicates That the Gastric Pouch and Roux Limb Act as a Common Cavity. Obes Surg. 2015;25(10):1833-41. DOI: https://doi.org/10.1007/s11695-015-1639-1
Yehoshua RT, Eidelman LA, Stein M, Fichman S, Mazor A, Chen J, et al. Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment. Obes Surg. 2008;18(9):1083. DOI: https://doi.org/10.1007/s11695-008-9576-x
Brauner E, Mahajna A, Assalia A. Intestinal malrotation presenting as midgut volvulus after massive weight loss following laparoscopic sleeve gastrectomy: case report and review of the literature. Surgery for Obesity and Related Diseases. 2012;8(4):52-5. DOI: https://doi.org/10.1016/j.soard.2011.04.229
Huang R, Gagner M. A Thickness Calibration Device Is Needed to Determine Staple Height and Avoid Leaks in Laparoscopic Sleeve Gastrectomy. Obes Surg. 2015;25(12):2360-7. DOI: https://doi.org/10.1007/s11695-015-1705-8
Sillén L, Andersson E, Olbers T, Edholm D. Obstruction after Sleeve Gastrectomy, Prevalence, and Interventions: a Cohort Study of 9,726 Patients with Data from the Scandinavian Obesity Surgery Registry (SOReg). Obes Surg. 2021;31(11):4701-7. DOI: https://doi.org/10.1007/s11695-021-05574-9
Spotnitz WD. Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive—a Laboratory and Clinical Perspective. ISRN Surg. 2014;2014:1-28. DOI: https://doi.org/10.1155/2014/203943
Chen YS, Loh EW, Shen SC, Su YH, Tam KW. Efficacy of Fibrin Sealant in Reducing Complication Risk After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg. 2021;31(3):1158-67. DOI: https://doi.org/10.1007/s11695-020-05098-8
Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T. Laparoscopic Omental Patch Repair for Perforated Peptic Ulcer. Ann Surg. 1995;221(3):236-40. DOI: https://doi.org/10.1097/00000658-199503000-00004
Zarzycki P, Kulawik J, Małczak P, Rubinkiewicz M, Wierdak M, Major P. Laparoscopic Sleeve Gastrectomy with Omentopexy: Is It Really a Promising Method. A Systematic Review with Meta-analysis. Obes Surg. 2021;31(6):2709-16. DOI: https://doi.org/10.1007/s11695-021-05327-8
Rosenthal RJ. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Rel Dis. 2012;8(1):8-19. DOI: https://doi.org/10.1016/j.soard.2011.10.019
Shikora SA, Mahoney CB. Clinical Benefit of Gastric Staple Line Reinforcement (SLR) in Gastrointestinal Surgery: a Meta-analysis. Obes Surg. 2015;25(7):1133-41. DOI: https://doi.org/10.1007/s11695-015-1703-x
Taha O, Abdelaal M, Talaat M, Abozeid M. A Randomized Comparison Between Staple-Line Oversewing Versus No Reinforcement During Laparoscopic Vertical Sleeve Gastrectomy. Obes Surg. 2018;28(1):218-25. DOI: https://doi.org/10.1007/s11695-017-2835-y
Tettero OM, Monpellier VM, Janssen IMC, Steenhuis IHM, van Stralen MM. Early Postoperative Weight Loss Predicts Weight Loss up to 5 Years After Roux-En-Y Gastric Bypass, Banded Roux-En-Y Gastric Bypass, and Sleeve Gastrectomy. Obes Surg. 2022;32(9):2891-902. DOI: https://doi.org/10.1007/s11695-022-06166-x
Manning S, Pucci A, Carter NC, Elkalaawy M, Querci G, Magno S, et al. Early postoperative weight loss predicts maximal weight loss after sleeve gastrectomy and Roux-en-Y gastric bypass. Surg Endosc. 2015;29(6):1484-91. DOI: https://doi.org/10.1007/s00464-014-3829-7
Noel P, Nedelcu M, Gagner M. Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016;26(8):1782-7. DOI: https://doi.org/10.1007/s11695-015-2003-1
Downloads
Published
How to Cite
Issue
Section
