A comparison of a single center's experience with three staple line reinforcement techniques in 1,502 laparoscopic sleeve gastrectomy patients

Reinforcement in Laparoscopic Sleeve Gastrectomy: Is It Effective?

BACKGROUND

Despite the success of bariatric surgery in treating obesity, it can still lead to complications. The most serious and feared technical complications are bleeding and leakage from the gastric staple line. In this study, stapler line reinforcement was investigated to determine whether it affects postoperative leakage and bleeding rates and their management.

MATERIALS AND METHODS

Overall, 510 patients who underwent sleeve gastrectomy were evaluated retrospectively. They were divided into 2 groups according to whether reinforcement of the staple line with running imbricating sutures was performed.

RESULTS

In the reinforcement group, there were two leaks (0.7%), which were diagnosed seven and eight days after surgery. In the non-reinforcement group, there were nine leaks (4%). There was no difference between the two groups in staple line bleeding.

CONCLUSIONS

This study shows that reinforcement with continuous imbricating sutures is associated with less stapler line leakage and a lower reoperation rate at the cost of increased operative time.

How Does Oversewing/Suturing (OS/S) Compare to Other Staple Line Reinforcement Methods? A Systematic Review and Meta-Analysis

Various staple line reinforcement (SLR) techniques in sleeve gastrectomy, including oversewing/suturing (OS/S), gluing, and buttressing, have emerged to mitigate postoperative complications such as bleeding and leaks. A meta-analysis of randomized controlled trials has demonstrated OS/S as an efficacious strategy for preventing postoperative complications, encompassing leaks, bleeding, and reoperations. Given that OS/S is the sole SLR technique not incurring additional costs during surgery, our study aimed to compare postoperative outcomes associated with OS/S versus alternative SLR methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed the literature and conducted fifteen pairwise meta-analyses of comparative studies, each evaluating an outcome between OS/S and another SLR technique. Thirteen of these analyses showed no statistically significant differences, whereas two revealed notable distinctions.

A comparative study between staple line reinforcement during laparoscopic sleeve gastrectomy and no reinforcement: an Egyptian experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years.

PATIENTS AND METHODS

This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR.

RESULTS

The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289).

CONCLUSION

This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.

Outcomes of Staple Line Reinforcement Following Robotic Assisted Sleeve Gastrectomy Based on MBSAQIP Database

INTRODUCTION

The objective of this study is to evaluate the outcomes for Staple Line Reinforcement (SLR) in RA-SG based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for 2019.

MATERIALS AND METHODS

We selected patients who underwent RA-SG in the MBSAQIP PUF (Public Utility File) for the year 2019 and grouped them based on their SLR status: Oversewing (OS), Buttressing (BR), both OS and BR and neither. Our primary outcomes were bleeding, organ space infection (OSI), and adverse events (AEs), and our secondary outcomes were operation length, hospital length of stay, readmissions, and conversion to open rates. We conducted separate chi square or one-way analysis of variance (ANOVA) as appropriate and multivariable direct logistic regression models for the categorical outcomes.

RESULTS

We found 115,621 patients with complete data of which there were 16,494 who underwent RA-SG. Our results did not show a statistically significant decrease in incidence of postoperative bleeding for BR and OS (Adjusted OR = 0.782, p = 0.2291 and Adjusted OR of 0.482, p = 0.054 for BR and OS respectively). There was a statistically significant effect for SLR status on operation length, with OS patients having the highest operative times (log-transformed mean = 2.03), followed by both BR + OS patients (log-transformed mean = 1.99). BR patients had the shortest operation length.

CONCLUSION

SLR did not result in any significant differences related to bleeding, OSI or AEs following RA-SG according to MBSAQIP for the year 2019. However, OS resulted in significantly longer operative time compared to BR alone.

The clinical effectiveness of staple line reinforcement with different matrix used in surgery

Staplers are widely used in clinics; however, complications such as bleeding and leakage remain a challenge for surgeons. To tackle this issue, buttress materials are recommended to reinforce the staple line. This Review provides a systematic summary of the characteristics and applications of the buttress materials. First, the physical and chemical properties of synthetic polymer materials and extracellular matrix used for the buttress materials are introduced, as well as their pros and cons in clinical applications. Second, we review the clinical effects of reinforcement mesh in pneumonectomy, sleeve gastrectomy, pancreatectomy, and colorectal resection. Based on the analysis of numerous research data, we believe that buttress materials play a crucial role in increasing staple line strength and reducing the probability of complications, such as bleeding and leakage. However, considering the requirements of bioactivity, degradability, and biosafety, non-crosslinked small intestinal submucosa (SIS) matrix material is the preferred candidate. It has high research and application value, but further studies are required to confirm this. The aim of this Review is to provide comprehensive guidance on the selection of materials for staple line reinforcement.

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.

Long-term (11 + years) efficacy of sleeve gastrectomy as a stand-alone bariatric procedure: a single-center retrospective observational study

INTRODUCTION

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure worldwide. The aim of the present study was to evaluate the long-term efficacy of SG as a stand-alone bariatric procedure.

METHODS

A single-center retrospective analysis of 104 patients who underwent SG as a stand-alone bariatric procedure between January 2005 and December 2009. Weight loss, weight regain, remission or improvement of comorbidities and the new onset of comorbidities were the main outcomes of the study.

RESULTS

The percent excess body weight loss (%EBWL), percent excess body mass weight (BMI) loss (%EBMIL), and percent total body weight loss (%TBWL) were 59 ± 25, 69 ± 29, and 29 ± 12, respectively, after a mean follow-up of 13.4 years. At the last follow-up, nearly two thirds of patients (67.3%) had an %EBWL greater than 50. The percentage of patients who experienced significant weight regain ranged from 47 to 64%, depending on the definition used for weight regain. The rate of improvement or remission of hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and degenerative joint disease at a mean follow-up of 13.4 years was 40%, 94.7%, 70%, 100%, and 42.9%, respectively. The new onset of gastroesophageal reflux disease (GERD) symptoms in the same period was 43%.

CONCLUSION

Our data supports that SG results in long-lasting weight loss in the majority of patients and acceptable rates of remission or improvement of comorbidities. Weight regain and GERD may be issues of particular concern during long-term follow-up after SG.

Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study

Introduction: Staple-line bleeding and gastric leakage are the most serious complications of laparoscopic sleeve gastrectomy (LSG). Reinforcement of the staple line is reported to be a method to reduce these complications rates, but the question of which method is preferable is a matter of controversy in the literature. In this study, we compared different staple-line reinforcement methods to assess their efficiency in preventing staple-line bleeding and leakage. Materials and Methods: Two hundred patients eligible for LSG were enrolled in the study and randomized into five groups based on the reinforcement method used during surgery: no reinforcement, oversewing using 3-0 polydioxanone (PDS) suture, oversewing using 4-0 barbed absorbable closure device (V-Lock), fibrin sealant glue, and buttress material. Intraoperative and postoperative complications were recorded and analyzed. Differences were considered statistically significant for P < .05. Results: The no-reinforcement group showed higher bleeding rates (20%), although only 2.5% of the patients required reintervention. All groups using staple-line reinforcement showed better outcomes in bleeding rates (P < .05). No statistically significant differences were observed among the groups in terms of the leakage rate, reintervention rate, intraoperative complications, and operative times. Conclusion: The reinforcement of the staple line decreased the bleeding rate in sleeve gastrectomy but did not affect the gastric leakage rate.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Purpose

Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR.

Materials and Methods

Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures.

Results

Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality.

Conclusions

SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05950-z.

Sleeve Gastrectomy Performed with Single Staple Height and Bioabsorbable Reinforcement in a Single Surgeon > 2500 Consecutive Case Series: Is Smart Technology Necessary?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is shown to have durable and sustained weight reduction outcomes and improvement in comorbid conditions in patients with severe clinical obesity. Discussions regarding "proper" staple height for various gastric locations continue. We propose a standard approach of consistent use of single staple load height and bioabsorbable staple line reinforcement during the LSG to reduce variability.

METHODS

A retrospective chart review of 2556 consecutive cases of adult patients who underwent LSG evaluated perioperative complications, postoperative leaks or bleeding, and average weight and body mass index (BMI) change and excess weight loss (EWL) at 6, 12, and 24 months. The same green staple load (2.0 mm) and staple line reinforcement were used in all cases for all staple firings, regardless of patient size or gastric location.

RESULTS

Patients were a mean age of 42 years, 87.3% were female, and the mean preoperative weight was 134.2 kg and BMI was 48.2 kg/m². No staple line leak was detected. Three bleeding events occurred but did not require readmission or rehospitalization. Mean EWL and BMI, respectively, were 49.0% and 35.5 kg/m² at 6 months, 69.8% and 29.6 kg/m² at 12 months, and 70.0% and 29.5 kg/m² at 24 months.

CONCLUSION

In this case series of 2556 consecutive LSG performed by a single surgeon, clinically meaningful EWL and decreased BMI were achieved. Streamlining the LSG procedure by utilizing the same staple height and a bioabsorbable staple line reinforcement proved safe with minimal complications.

Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies

Purpose

Among various staple-line reinforcement methods applied during sleeve gastrectomy (SG), although data on full-thickness-continuous-suturing (FTCS) is nearly nil, it has been considered as potentially harmful. The safety/efficacy profile of FTCS is assessed.

Methods

All consecutive SGs completing 3-month follow-up were studied. Data on peri-operative parameters, complications, and follow-up were prospectively recorded. All reinforcements were completed by FTCS utilizing barbed suture. Super-super obese, secondary SGs, SGs performed in patients with prior anti-reflux surgery, and SGs performed with additional concomitant procedures were evaluated as “technically demanding” SGs. Student’s t/chi-square tests were used as appropriate.

Results

Between January 2012 and July 2020, 1008 SGs (941 “primary-standard,” 67 “technically demanding”) were performed without mortality/venous event. Single leak occurred in a patient with sleeve obstruction (0.1%). Thirteen bleedings, 4 requiring re-surgery (0.4%), and 17 stenoses (1.7%) were encountered. Four stenoses were treated with gastric bypass (1 emergency), 6 by dilatation(s), and one required parenteral nutrition. Six patients with stenosis chose not to have any treatment. No statistically significant difference was observed in postoperative complications between “primary-standard” and “technically demanding” SGs (p > 0.05). The median follow-up was 44 months. The excess weight loss % at 5th year was 80.1%. Suturing added 28.4 ± 6 minutes to the SG, 3 or fewer sutures were used to complete the reinforcement in > 95%. No mishap/complication occurred related to suturing.

Conclusion

FTCS produced excellent result in terms of leakage/hemorrhage with an acceptable stenosis rate at a low cost with half-an-hour increase in the operating time. In contrast to previous allegations, no harm attributable to stitching itself occurred.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02161-5.

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

Background

Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM).

Methods

This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options.

Results

Of the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).

Conclusions

This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-06782-2) contains supplementary material, which is available to authorized users.

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.

Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) has become one of the most commonly performed bariatric procedures, largely due to several advantages it carries over more complex bariatric procedures. LSG is generally considered a straightforward procedure, but one of the major concerns is a staple line leak.

OBJECTIVE

The objectives of this study are to evaluate the correlation between surgeon's experience and leak rate and to assess the different risk factors for developing a gastric leak after LSG.

SETTING

Private hospital, France.

METHODS

The analysis of a single surgeon's yearly leak rate since the introduction of LSG for possible risk factors was done.

RESULTS

A total of 2012 LSGs were performed in between September, 2005 and December, 2014. Twenty cases (1 %) of gastric leak were recorded. Of these, 17 patients were women (94.4 %) with a mean age of 39.4 years (range 22-61) and mean body mass index (BMI) 41.2 kg/m(2) (range 34.8-57.1). On a yearly basis, the leak rate was 4.8 % (2006), 5.7 % (2007), 0 (2008), 2.6 % (2009), 2 % (2010), 0.8 % (2011), 0.6 % (2012), 0.2 % (2013), and 0 (2014). In the first 1000 cases (group A), there were 18 cases of gastric leak and in the last 1000 cases, there were 800 with GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement (group B) 2 cases of gastric leak (p = 0.009). A revisional LSG, 395 patients after gastric banding and 61 patients re-sleeve gastrectomy, was performed in 456 cases (22.7 %). There were 3 cases of leak (0.65 %). There were two deaths.

CONCLUSION

LSG can be performed with a low complication rate. This large series of a single surgeon's experience demonstrated that the leak rate after LSG could be significantly decreased over time with changes in techniques.

Evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients

BACKGROUND

Both hiatal hernias (HH) and morbid obesity significantly contribute to gastroesophageal reflux disease, which increases the risk for esophagitis and esophageal cancer. Therefore, concomitant HH repair is recommended during bariatric surgery procedures. Unfortunately, recurrence of HH after repair is not uncommon and the optimal surgical technique has yet to be established.

OBJECTIVE

To evaluate the feasibility of recreating the phrenoesophageal ligaments by adding phrenoesophagopexy to HH repair during sleeve gastrectomy.

SETTING

Independent, university-affiliated teaching hospital.

METHODS

Retrospective chart review of all patients with a body mass index ≥35 kg/m² who underwent a combined sleeve gastrectomy and HH repair between January 2010 and December 2014 by a single surgeon at a single institution. Demographic data and 30-day postoperative complications rates were obtained.

RESULTS

There were 106 patients evaluated. Mean age was 50.8 ± 12.5 years, mean body mass index was 45.8 ± 7.1 kg/m², and 87% were female. Mean operative time was 112 ± 24.5 minutes, and mean length of stay was 1.9 ± .7 days. The 30-day complication rate was .94% (1 gastric sleeve leak) and there were no deaths. Six patients (5.7%) required emergency department evaluation, and 5 (4.7%) required readmission for abdominal pain (2), dysphagia/dehydration (1), esophagitis (1), or gastric sleeve leak (1), which required reoperation.

CONCLUSION

The addition of an interrupted phrenoesophagopexy for HH repair during sleeve gastrectomy appears to be a feasible technique with low 30-day morbidity and mortality rates. Long-term follow-up is needed to evaluate the efficacy in reducing HH recurrence rates.

Staple line oversewing during laparoscopic sleeve gastrectomy

Introduction This meta-analysis was performed to assess the possible benefits of staple line oversewing during laparoscopic sleeve gastrectomy. Methods A comprehensive search up to February 2017 was conducted on PubMed, the Web of Science™ and Embase™. All eligible studies were included, and the outcomes of staple line bleeding and leak, overall complications and operative time were pooled. Results A total of 7 randomised controlled trials involving 845 patients (428 cases and 417 controls) were analysed. There was no significant difference in staple line bleeding (relative risk [RR]: 0.858, 95% confidence interval [CI]: 0.343-2.143, p=0.742), leak (RR: 0.650, 95% CI: 0.257-1.644, p=0.363) or overall complications (RR: 0.913, 95% CI: 0.621-1.342, p=0.644) between the oversewing group and the patients who did not have oversewing. Oversewing of the staple line was associated with a longer operative time (weighted mean difference: 14.400, 95% CI: 7.198-21.602, p=0.000). Conclusions Oversewing the staple line during laparoscopic sleeve gastrectomy does not decrease the risk of staple line bleeding, leakage or overall complications but it does prolong the operative time.

Surgical glue in laparoscopic sleeve gastrectomy: An initial experience and cost-effectiveness analysis

RATIONALE, AIMS, AND OBJECTIVES

Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures. Gastric leaks and bleeding are the most frequent complications, associated with a high clinical and economic burden. The best method of staple line reinforcement in LSG is debated. Surgical glue is one of the options available. The aim of this study was to assess the safety, efficiency, and relative cost-effectiveness of surgical glue used to perform LSG in morbid obese adults as compared with standard stapling.

METHODS

A prospective, observational, and comparative before-after study was conducted. All consecutive patients undergoing LSG at Montpellier University Hospital in 2011 and 2012 were included and treated according to 2 groups: standard stapling (n = 99, group 1) and surgical glue reinforcement (n = 94, group 2). Clinical and economic outcomes were measured after 6 months.

RESULTS

The duration of intervention was significantly shorter in group 2 (68 vs 82 minutes, P = .001). There was no significant difference regarding complications, but leaks in group 1 were more severe. Group 2 was also associated with a reduced initial length of stay (4.8 vs 5.2 days, P = .01). Six-month readmissions and total length of stay were also shorter in group 2 (5.5 vs 6.1 days, P = .003). Surgical glue use was associated with a significant reduction in the initial inpatient cost (€5488 vs €6152, P = .005) and in the 6-month total inpatient cost, including readmissions (€6006 vs €6754, P = .005). The incremental cost of glue to avoid a severe complication was -€5446.33 (95 confidence interval, -8202.01 to -2690.66).

CONCLUSIONS

Surgical glue might be a safe and cost-effective intervention in laparoscopic sleeve gastrectomy.

Prospective evaluation of routine early computed tomography scanner in laparoscopic sleeve gastrectomy

BACKGROUND

Prompt management of laparoscopic sleeve gastrectomy (LSG) complications is essential in avoiding prolonged hospital stay and associated mortality. The value of routine computed tomography (CT) scan examination in early diagnosis of postoperative complications after LSG has not been studied.

OBJECTIVES

To prospectively assess the impact of postoperative day (POD) 2 CT scan after LSG.

SETTING

Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France.

METHODS

Data were prospectively gathered for 1000 patients undergoing single-incision LSG and POD 2 CT scan. Complications were identified and treatment modalities decided according to the severity of complications. Sensitivity, specificity, and positive and negative predictive values were calculated for the diagnosis of surgical complications on POD 2 CT scan.

RESULTS

Mean age was 40.1 years and median BMI 42.6 kg/m². Early postoperative surgical complications occurred in 66 patients (6.6%). Intraabdominal bleeding/hematoma occurred in 38 patients, with 3 requiring emergent reoperation on POD 1. POD 2 CT scan detected this complication in 32 patients (sensitivity: 91.4%). Twenty-four (63.1%) patients were treated with relaparoscopy and drainage while 14 (36.9%) received conservative management. Postoperative transfusion was required in 7 patients. Twenty-eight patients suffered a gastric staple line leak, 13 (sensitivity: 46.4%) detected on POD 2 CT scan. Three patients (10.7%) received pure surgical treatment, 16 (57.1%) combined relaparoscopy and endoscopic treatment, and 9 (32.2%) had pure endoscopic treatment.

CONCLUSION

POD 2 abdominal CT scan is an efficient diagnostic tool for detecting active bleeding/hematoma, but shows less impressive results with gastric staple line leak detection. A combination of clinical surveillance and early imaging allowed prompt management of complicated cases, avoiding further morbidity.

Hospital variation in rates of acid-reducing medication use after laparoscopic sleeve gastrectomy

BACKGROUND

Postoperative gastroesophageal reflux is one of the most important long-term complications of sleeve gastrectomy, the most common bariatric procedure.

OBJECTIVE

To assess variation in hospital performance with laparoscopic sleeve gastrectomy using rates of acid-reducing medication use at postoperative 1 year.

SETTING

Clinical registry of bariatric surgical patients at academic and community hospitals in Michigan.

METHODS

We studied 2923 patients who underwent laparoscopic sleeve gastrectomy across 39 hospitals in the Michigan Bariatric Surgery Collaborative, 2007 to 2014. We compared risk- and reliability-adjusted rates of new-onset reflux-defined by new use of acid-reducing medication-across hospitals and in relation to surgical quality indicators (hospital procedure volume and 30-day complications).

RESULTS

Overall, 20% of patients were newly taking acid-reducing medication at postoperative 1 year. Hospital rates of new medication use varied 3-fold, ranging from 10% (95% CI 7-15%) to 31% (95% CI 23-40%) of patients. Of the 2 hospitals with significantly lower rates of new medication use, 1 was high volume and 1 was medium volume. The 1 hospital with significantly higher rates was medium volume. Rates of acid-reducing medication use did not correlate with hospital volume or perioperative complications.

CONCLUSION

Across Michigan hospitals, rates of new acid-reducing medication use at 1 year after laparoscopic sleeve gastrectomy varied widely and did not correlate with traditional quality indicators. Future research could explore differences in surgical technique to better understand the factors underlying variation in long-term outcomes after sleeve gastrectomy.

Hospital variation in perioperative complications for laparoscopic sleeve gastrectomy in Michigan

BACKGROUND

Laparoscopic sleeve gastrectomy has surpassed gastric bypass and laparoscopic adjustable gastric banding recently as the most common weight-loss procedure. Previously, substantial concerns existed regarding variation in perioperative safety with bariatric surgery. This study aimed to assess rates of perioperative complications for laparoscopic sleeve gastrectomy across hospitals and in relation to procedure volume within the Michigan Bariatric Surgery Collaborative.

STUDY DESIGN

We analyzed 8,693 patients who underwent laparoscopic sleeve gastrectomy from 2013 through 2014 across 40 hospitals in the Michigan Bariatric Surgery Collaborative. Mixed-effects logistic regression was used to assess hospital variation in risk- and reliability-adjusted rates of overall and serious 30-day complications and their relationship with hospital annual volume of stapling procedures (gastric bypass and sleeve gastrectomy).

RESULTS

Overall, 5.4% of patients experienced perioperative complications. Adjusted rates of overall complications varied three-fold across hospitals, ranging from 3.6% (95% confidence interval 1.9-6.8%) to 11.0% (95% confidence interval 7.7-15.5%). Serious complications occurred in just 1.2% of patients and varied minimally. In this analysis, hospital volume was not associated with overall or serious complications. The 1 hospital with significantly less overall complication rates was high-volume (≥ 125 procedures/year); however, of the 4 hospitals with significantly greater complication rates, 3 were medium-volume (50-124 procedures/year), and 1 was high-volume. The remaining hospitals were not significantly different than the cohort mean.

CONCLUSION

Serious complications among patients undergoing laparoscopic sleeve gastrectomy were relatively infrequent in this cohort of patients in the Michigan Bariatric Surgery Collaborative. Rates of overall complications varied widely across the hospitals enrolled in this statewide quality collaborative, although this variation was unrelated to volume standards required for accreditation as a comprehensive bariatric surgery center.