Postoperative bleeding and leaks in sleeve gastrectomy are independent of both staple height and staple line oversewing

Managing Leaks and Fistulas After Laparoscopic Sleeve Gastrectomy: Challenges and Solutions

Postoperative leaks after sleeve gastrectomy are a troublesome complication that occur in 0.7-5.3% of cases depending on the referenced source. These complications cause significant morbidity for patients requiring prolonged hospitalizations, nutritional support, intravenous antibiotics, and at times additional operations and procedures that risk further downstream complications. The patient presentation varies from relatively benign with minimal or no symptomatology, to the acutely ill with life-threatening sepsis. The management of gastric leak is dependent on a multitude of factors, including the initial presentation as well the surgeon's experience and preference. Here, we will summarize the current literature and discuss the different options that exist for the management of gastric leaks after sleeve gastrectomy including laparoscopic lavage, endoscopic stenting, endoscopic pigtail catheters, endoscopic vacuum therapy, and salvage surgical operations such as fistula jejunostomy and total gastrectomy. The aim is to provide a source for surgeons to reference when they encounter this disease pathology and to shed light on a daunting challenge for the modern bariatric surgeon.

[Treatment and prevention of suture failure and bleeding after various bariatric interventions]

OBJECTIVE

To assess the incidence, treatment and prevention of leakage, as well as bleeding after various types of bariatric interventions.

MATERIAL AND METHODS

There were 3.107 various bariatric interventions between 2020 and 2024 including 1.403 (45.2%) laparoscopic sleeve gastrectomies (LSG), 1.622 (52.2%) laparoscopic mini/one anastomosis gastric bypass procedures (MGB-OAGB) and 82 (2.6%) laparoscopic Roux-en-Y gastric bypass surgeries (RYGB). The incidence of intraperitoneal and intraluminal bleeding, suture failure and incidence of complications depending on intraoperative prevention were evaluated. Efficacy of endoscopic VAC system (vacuum-assisted closure) for suture failure after LSG, MGB-OAGB and RYGB was evaluated.

RESULTS

The overall complication rate between 2020 and 2024 was 1.64% (51 patients), suture failure - 0.45% (14 patients), bleeding - 0.71% (22) cases. Ten (71.4%) patients with suture failure were treated using VAC system. In 9 patients, the defect recovered without external gastric fistula. In 5 patients, defect closure was primary, in 4 patients - secondary, i.e. through ulcerative defect. In 1 patient after LSG, the defect did not heal despite VAC therapy for 21 days, and external gastric fistula occurred. Double treatment of stapler line for prevention of postoperative bleeding and leakage reduced the incidence of leaks by 2.5 times, intra-abdominal bleeding by 23 times, intraluminal bleeding from 0.95% to 0%.

CONCLUSION

Endoscopic VAC system is effective for suture failure after bariatric interventions. Double treatment of stapler suture line can significantly reduce the incidence of bleeding and leakage after LSG, MGB-OAGB and RYGB.

The Risk of Leakage and Bleeding After Using the Ezisurg Endostapler Technique for Bariatric Surgery

BACKGROUND

Obesity is a growing global health issue, with a prevalence rate of 28.8% in Jordan. Bariatric surgery is the most effective treatment for morbid obesity, yet complications such as postoperative bleeding and leakage remain significant concerns. This study evaluates the safety and effectiveness of the Ezisurg endostapler (Ezisurg Medical, Shanghai, China) in laparoscopic bariatric surgery by assessing the prevalence of these complications.

METHODS

A retrospective, single-center study was conducted at King Hussein Medical Hospital, Amman, Jordan. Records of 400 consecutive patients who underwent laparoscopic bariatric surgery between September 2023 and August 2024 were reviewed. Intraoperative assessment of leakage was conducted using CT scans with methylene blue test, while postoperative leakage was evaluated through Gastrografin testing and abdominal CT scans. Bleeding was assessed according to the Bleeding Academic Research Consortium (BARC) criteria. Data on patient demographics, procedure types, intraoperative and postoperative complications, and outcomes were systematically collected. Qualitative variables were summarized through frequencies and percentages, while quantitative variables were described with measures of median and interquartile range (IQR). A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 400 patients, predominantly women (80%), with a median age of 34.0 years and a median body mass index (BMI) of 43.0 kg/m² were included. Around two-thirds of patients underwent laparoscopic sleeve gastrectomy (LSG), and the other third underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). The median operation time was 96 minutes. Postoperative complications occurred in 10 patients (3.6%), including bleeding in five patients (1.25%) and leakage in three patients (0.75%). Five (1.25%) patients had postoperative bleeding, of which two were treated conservatively and three required surgical reoperation, two at the trocar site and one at the stapler line.

CONCLUSIONS

 The Ezisurg endostapler showed low rates of postoperative bleeding (1.25%) and leakage (0.75%), highlighting its safety and effectiveness in laparoscopic bariatric surgery. Multicenter studies and long-term follow-ups are recommended to confirm these findings, evaluate cost-effectiveness, and explore patient-specific risk factors to further improve outcomes.

Don't Fear the Bleed: Assessing Postoperative Bleeding Incidence After Instituting a Standardized Prophylactic Heparin Protocol in Bariatric Patients

Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for ∼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.

Oversewing the Staple Line: Does It Safe to Prevent Leakage?

Introduction: The staple line (SL) leak remains one of the most serious complications after laparoscopic sleeve gastrectomy (LSG). The present study aims to determine whether reinforcing the SL with sutures is effective in maintaining tissue integrity. Materials and Methods: LSG Specimens of 60 patients were ex vivo studied. The specimens were divided into three groups: In group 1, the entire SL was reinforced, while the upper half part of the SL was reinforced from fundus to antrum in group 2. The SL was not reinforced in group 3. Then, the pressure inside the sample was increased, and the bursting pressure location and pressure value during the bursting were recorded. Results: The bursting pressure was significantly higher in entire and half oversewed SL groups than the none reinforced group (group 1: 115 mmHg [95-170]; group 2: 95 mmHg [80-120]; group 3: 40 mmHg [22-60], respectively, [P < .001]). The most common site of bursting was in the middle ⅓ of SL (35, 53.8%), followed by the proximal ⅓ part of SL (18, 27.7%), and the distal ⅓ part of SL (12, 18.5%), respectively. The bursting site was significantly more frequent in the corpus than the other parts of the SL (P = .013). Conclusion: Reinforcing the SL with sutures preserves tissue integrity. Although bursting was most frequently observed in the corpus region ex vivo, the fact that almost all real-life leaks develop in the area close to the Angle of His. This situation suggests that strengthening the suture line with reinforcement alone will not be protective enough against leaks in the fundus line, and factors such as tissue ischemia may be considered.

The Role of Tranexamic Acid in Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing laparoscopic sleeve gastrectomy (LSG) is still unresolved. Therefore, this meta-analysis evaluated and investigated the current intra- and postoperative effects and hazards of TXA on patients undergoing LSG. As for methodology, Web of Science, Cochrane Library, Scopus, and PubMed were thoroughly searched for relevant studies. Retrieved results were prepared for screening through Endnote, helping to identify eligible studies. Relevant patient characteristics and outcomes were extracted. The methodological quality of the relevant studies was appraised using the respected appraisal tool. Six studies of different designs were enrolled, comprising 753 cases that underwent LSG and administered TXA. Their mean BMI and age went from 37.3 to 56.25 kg/m2 and 33.5 to 43.25 years, respectively. Tranexamic acid significantly linked to reduction in intraoperative bleeding instances, operative blood loss, and operative duration, compared to placebo ((RR = 0.66, 95% CI [0.44, 0.98], P=0.04, I2 = 81%); (MD = -39.64, 95%CI [-75.49, -3.78], P=0.03, I2=94%); (MD=-5.84, 95%CI [-9.62, -2.05], P=0.003, I2=73%)). Tranexamic acid also significantly showed superiority regarding postoperative bleeding events and duration of hospitalization compared to the control group ((RR= 0.45, 95%CI [0.29, 0.69], P=0.0002, I2 =0%); (MD=-0.24, 95%CI [-0.32, -0.17], P< 0.0000, I2 =0%)). Moreover, follow-up of the enrolled patients for a minimum of three to six months resulted in no reported thromboembolic instances, suggesting a negligible risk for thromboembolism among patients undergoing LSG and receiving TXA. In conclusion, tranexamic acid demonstrates a robust safety and efficacy profile for its use in patients undergoing LSG, with no reported instances of thromboembolism. Variations in TXA administration regimens, bleeding definitions, procedural techniques, and potential confounding medications could not be accounted for, necessitating additional large-scale RCTs to address and bridge knowledge gaps.

Peroperative administration of tranexamic acid in sleeve gastrectomy to reduce hemorrhage: a double-blind randomized controlled trial

INTRODUCTION

In metabolic surgery, hemorrhage is the most common major complication. This study investigated whether peroperative administration of tranexamic acid (TXA) reduced the risk of hemorrhage in patients undergoing laparoscopic sleeve gastrectomy (SG).

METHODS

In this double-blind randomized controlled trial, patients undergoing primary SG in a high-volume bariatric hospital were randomized (1:1) to receive 1500-mg TXA or placebo peroperatively. Primary outcome measure was peroperative staple line reinforcement using hemostatic clips. Secondary outcome measures were peroperative fibrin sealant use and blood loss, postoperative hemoglobin, heart rate, pain, major and minor complications, length of hospital stay (LOS), side effects of TXA (i.e., venous thrombotic event (VTE)) and mortality.

RESULTS

In total, 101 patients were analyzed and received TXA (n = 49) or placebo (n = 52). There was no statistically significant difference in hemostatic clip devices used in both groups (69% versus 83%, p = 0.161). TXA administration showed significant positive changes in hemoglobin levels (millimoles per Liter; 0.55 versus 0.80, p = 0.013), in heart rate (beats per minute; -4.6 versus 2.5; p = 0.013), in minor complications (Clavien-Dindo ≤ 2, 2.0% versus 17.3%, p = 0.016), and in mean LOS (hours; 30.8 versus 36.7, p = 0.013). One patient in the placebo-group underwent radiological intervention for postoperative hemorrhage. No VTE or mortality was reported.

CONCLUSION

This study did not demonstrate a statistically significant difference in use of hemostatic clip devices and major complications after peroperative administration of TXA. However, TXA seems to have positive effects on clinical parameters, minor complications, and LOS in patients undergoing SG, without increasing the risk of VTE. Larger studies are needed to investigate the effect of TXA on postoperative major complications.