Comparison between orogastric tube/bougie and a suction calibration system for effects on operative duration, staple-line corkscrewing, and esophageal perforation during laparoscopic sleeve gastrectomy

Integrating minimally invasive bariatric surgery with lessons from gastric cancer surgery

Laparoscopic procedures in bariatric surgery are evolving to enhance cosmetic outcomes and minimize postoperative complications. This study demonstrates the results of bariatric surgery achieved through the application of surgical techniques derived from gastric cancer surgery. Several surgical techniques from gastric cancer surgery were implemented in bariatric surgery, including: (1) V-shaped liver retraction, (2) Reduced port surgery, (3) Intraoperative endoscopy and (4) Multi-degree-of-freedom articulating device. A single surgeon, with experience in over 1000 gastric cancer surgeries, performed consecutive bariatric surgeries starting from the initial case. The study analyzed short-term results, including operation details, postoperative complications, outcomes of weight loss, and the learning curve. A total 94 consecutive laparoscopic sleeve gastrectomy cases were performed from 2019 to 2022. The mean age of 94 patients was 35.9 ± 9.7 years, with 58 (61.7%) being female. The mean body mass index (BMI) was 40.9 ± 6.2. Type 2 diabetes was prevalent in 46.8% of the patients. On average, 3.3 ± 0.5 trocars were used per surgery. The mean estimated blood loss and hospital stay after surgery were 20.1 ± 36.3 cc and 3.3 ± 0.6 days, respectively. There were no complications reported for postoperative leakage, bleeding, or passage disturbance, and no mortality occurred. At 12 months, the mean percentage total weight loss (%TWL) and excess BMI loss (%EBMIL) were 28.5% and 79.7%, respectively. The mean operation times was 109.5 ± 27.4 min, with a plateau observed at around the 30th case. Bariatric surgery can be effectively performed by a gastric cancer expert surgeon using techniques derived from gastric cancer surgery.

Rare Complications Following Laparoscopic Sleeve Gastrectomy

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

Does the use of a suction calibration system (SCS) reduce stapler load firings and operative time? A randomized controlled trial comparing use of endoscopic calibration vs. SCS in laparoscopic sleeve gastrectomy

BACKGROUND

It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings.

METHODS

This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test.

RESULTS

A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications.

CONCLUSION

Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.

Is staple line reinforcement still needed on contemporary staplers? A benchtop analysis

BACKGROUND

Staple line reinforcement (SLR) is commonly used in bariatric surgeries to reduce leaks and bleeds. With the evolution of staplers, the need for buttressing with the latest surgical stapling technology is in question. The efficacy of GORE® SEAMGUARD® (G-SLR) to improve staple line strength based on an established measure of burst pressure was evaluated. A benchtop test on synthetic tissue evaluated the pressure required for staple line leak across surgical staplers with and without G-SLR.

METHODS

Staple lines on a consistent thickness synthetic bowel were pressurized to the point of failure (burst pressure) among Ethicon®, Intuitive®, and Medtronic® surgical staplers with and without G-SLR. Burst pressure and leak location (through the staple line [TTSL] or through the staple [TTS], on the anvil or cartridge side) were recorded. Visual confirmation of a leak concluded each test.

RESULTS

The pooled mean burst pressure for G-SLR was greater (p < 0.05) by 0.494 pounds/square inch compared with no reinforcement with no meaningful differences among staplers. Leak failures were primarily TTS (91.7%) and equally distributed between reinforcement groups with more leak failures on the cartridge side with G-SLR and on the anvil side for non-SLR group. Leaks occurred across the length of staple lines with no discernable pattern.

CONCLUSION

Employing a buttressing material strengthens the staple line, as measured by burst pressure, and may reduce the risk for staple line failure. This benchtop study of G-SLR with three commonly used surgical staplers demonstrated a significant increase in burst pressures among the studied stapling devices.

Decreased Leak Rate and Need for Reintervention with Use of Closed Suction Calibration System: a Bariatric Surgery Quality Improvement Project

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) continues to grow in popularity as a primary bariatric procedure. The purpose of this study is to determine if leak rates and need for subsequent interventions are changed by the standardized use of a closed suction calibration system (CSCS) at a high-volume urban hospital.

METHODS

A retrospective review was conducted between January 1, 2016, and December 31, 2018, on SG patients. All cases performed in 2018 were completed with a closed suction calibration system. Patient demographics, comorbidities, operative variables, and outcomes were collected. Descriptive statistics and chi-squared test were used to compare the two groups. Logistic regression models were adjusted for patient- and procedure-specific factors.

RESULTS

Four hundred ninety cases were performed before and 195 after institution of the CSCS. Groups were similar in most characteristics, including median body mass index (BMI) (46.4 vs 45.8 kg/m2, p = 0.79). Those in the closed suction cohort were more likely to have OSA requiring therapy (32.4% vs 46.6%, p < 0.01) and to have their cases performed robotically (55.4% vs 39.6%, p = 0.02). Post introduction of the CSCS, the overall leak rate was 0% (1.4% vs 0%, p = 0.09); overall need for postoperative interventions decreased (9.6% vs 2.6%, p = 0.009). After adjustment, a 69% decrease was observed in need for related additional intervention [aOR 0.31 (0.12-0.81), p = 0.017].

CONCLUSION

The use of a standardized closed suction calibration system resulted in overall decreased leak rates, which was associated with a clinically significant decrease in additional interventions.

Preoperative Dexamethasone for Airway-Related "Calibration Tube" Complications After Sleeve Gastrectomy: a Randomised Clinical Trial

BACKGROUND

Bariatric surgeries utilise Bougie device to guide stomach resection. The device implementation is associated with many underreported complications. This study aims to compare nebulised vs. intravenous preoperative dexamethasone in mitigating airway-related Bougie complications after sleeve gastrectomy.

METHODOLOGY

This is a prospective double-blinded interventional study conducted by a tertiary hospital. The study involved 105 patients allocated to 3 groups: Group (I) received 8 mg dexamethasone intravenously (IV) preoperatively, group (N) received 8 mg dexamethasone from a nebulizer mask preoperatively, and Group (S) received nebulised normal saline. Outcomes evaluated were postoperative sore throat, odynophagia, change of voice, and nausea and vomiting.

RESULTS

Nebulized dexamethasone was found to be significantly superior to IV dexamethasone in terms of postoperative sore throat at zero-hour (p = 0.001) and 1-h intervals (p = 0.011). No significant difference was found at 6- and 24-h intervals. For odynophagia, post hoc analysis showed there was no significant difference between (I), (N), and (S) groups. Incidence of change of voice was significantly lower in (N) and (I) groups compared to (S) group, with p values of 0.0067 and 0.00014, respectively. The incidence of post-operative sore-throat (PONV) in (I) group was significantly lower than incidences in (S) group (p = 0.00002) and (N) group (p = 0.0004).

CONCLUSION

Preoperative nebulized and IV dexamethasone are effective strategies in mitigating complications related to mechanical effects of Bougie insertion. IV dexamethasone was as effective as nebulized dexamethasone in terms of late postoperative sore throat, and was superior in postoperative nausea and vomiting.

Thoracic esophageal rupture during sleeve gastrectomy: a case report with successful laparoscopic transhiatal repair

While laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures for morbid obesity, the rate of complications is decreasing. These complications include hemorrhage and gastric leak that are considered life threatening. The esophageal complications in the form of perforation or rupture during LSG are rare and mainly because of iatrogenic reasons, such as blind, unguided instrumentation, which include the bougie (commonly used for gastric calibration during LSG). These complications are potential life threatening. The detection and management of these complications can affect the outcome and minimize the morbidity and avoid the incidence of mortality. We report a case of 38-year-old female, with a body mass index of 42 with iatrogenic rupture of distal and thoracic part of esophagus for >10-cm length during LSG and the immediate full laparoscopic transhiatal primary repair.

Safety of orogastric tubes in foregut and bariatric surgery

Background

Orogastric tubes have traditionally aided foregut procedures with sizing and organ protection. The rise of bariatric surgery has led to the creation of novel medical devices aimed at facilitating the laparoscopic sleeve gastrectomy. While approved by the FDA, the long-term safety profile of these devices in the general population is often unknown. This review looks at complications associated with novel Orogastric Tubes compared to the traditional bougie.

Methods

We performed a review of the Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for complications associated with the traditional bougie, Boehringer Labs ViSiGi 3D® and the Medtronic GastriSail™ since 2011. In addition, we looked for reported cases in the literature of complications with these devices.

Results

Overall complication rates reported in the MAUDE database varied in number and severity. The bougie had seven reported complications, one of which was an organ perforation. The ViSiGi 3D® had zero reported complications. The GastriSail™ had 36 total reported complications with 17 perforations. A literature review shows that rates of bougie complications are extremely rare with no case reports or reviews of complications from the novel orogastric tubes.

Conclusions

The complication rates between the traditional bougie and novel devices vary in number and severity, with the GastriSail™ having the highest reported complication rate. Despite rigorous testing for FDA approval, ongoing research into performance of new medical devices in the general population remains important.

Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study

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.