1
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Vosburg RW. Factors Related to Bleeding and Leak Rates After Robotic Sleeve Gastrectomy. Obes Surg 2023; 33:2658-2661. [PMID: 37434019 DOI: 10.1007/s11695-023-06712-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Robotic sleeve gastrectomy has been increasing in annual incidence in recent years. Although rare, post op bleeding and leak in these cases can lead to significant morbidity, mortality, and healthcare utilization. OBJECTIVES To determine preop comorbidity risk factors and operative techniques associated with risk of bleeding or leak within 30 days of robotic sleeve gastrectomy. METHODS The MBSAQIP database was analyzed. A total of 53,548 RSG cases were included in analysis. Surgeries took place from accredited centers in the USA from 2015 to 2019. CONCLUSIONS Preoperative anticoagulation, renal failure, COPD, and OSA were found to increase in the risk for transfusion requirements after SG. Receiving a transfusion and smoking increased the risk for leak. Staple line reinforcement significantly decreased transfusion and leak rates. Staple line oversewing did not have an impact on bleeding or leak.
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Affiliation(s)
- R Wesley Vosburg
- Department of Surgery, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, 02138, USA.
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2
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Diab ARF, Sher T, Awshah S, Noom M, Docimo S, Sujka JA, DuCoin CG. Oversewing/Suturing of the Staple Line During Sleeve Gastrectomy Is an Effective and Affordable Staple Line Reinforcement Method: a Meta-analysis of Randomized Controlled Trials. Obes Surg 2023; 33:2533-2545. [PMID: 37312007 DOI: 10.1007/s11695-023-06672-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/24/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
Bleeding and leaks are the most ominous postoperative complications after laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) techniques have been innovated such as oversewing/suturing (OS/S), omentopexy/gastropexy, buttressing, and gluing. Currently, no high-quality evidence supports the use of one method over the others or even supports the use of SLR over no SLR. This study aimed to compare postoperative outcomes between LSG with OS/S versus LSG without any SLR.
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Affiliation(s)
- Abdul-Rahman F Diab
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA.
| | - Theo Sher
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Sabrina Awshah
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Madison Noom
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Salvatore Docimo
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Joseph A Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Christopher G DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
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3
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Diab ARF, Alfieri S, Doyle W, Koussayer B, Docimo S, Sujka JA, DuCoin CG. Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies. Obes Surg 2023; 33:2237-2245. [PMID: 37204531 DOI: 10.1007/s11695-023-06649-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/07/2023] [Accepted: 05/12/2023] [Indexed: 05/20/2023]
Abstract
Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.
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Affiliation(s)
- Abdul-Rahman F Diab
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA.
| | - Sarah Alfieri
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - William Doyle
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Bilal Koussayer
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Salvatore Docimo
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Joseph A Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Christopher G DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
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4
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Chand B, Meyers C. Is staple line reinforcement still needed on contemporary staplers? A benchtop analysis. Surg Endosc 2023; 37:1274-1281. [PMID: 36175699 DOI: 10.1007/s00464-022-09644-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Bipan Chand
- Loyola University Medical Center, 2160 South First Ave, Maywood, IL, 60153, USA.
| | - Christen Meyers
- Loyola University Medical Center, 2160 South First Ave, Maywood, IL, 60153, USA
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5
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Eckharter C, Heeren N, Mongelli F, Sykora M, Mühlhäusser J, Lottenbach N, Scheiwiller A, Metzger J, Gass JM. Partial staple line reinforcement with synthetic buttressing material in laparoscopic sleeve gastrectomy: a propensity score-matched analysis. Langenbecks Arch Surg 2023; 408:47. [PMID: 36662323 PMCID: PMC9859840 DOI: 10.1007/s00423-023-02796-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/22/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE Staple line leakage (SLL) and staple line bleeding (SLB) are the most relevant postoperative complications of sleeve gastrectomy (SG). It is controversial whether and which method of staple line reinforcement (SLR) can best reduce these complications. The primary objective of this study was to investigate whether reinforcement of the most proximal part of the staple line with synthetic buttressing material, a strategy we termed partial SLR (p-SLR), reduces the 30-day incidence of SLL. METHODS A retrospective search of medical records of all bariatric patients from 2010 to 2019 was performed. Patients who underwent SG with either p-SLR or non-SLR were included. Intraoperative and postoperative outcomes were analyzed before and after propensity score matching (PSM). RESULTS Data from 431 patients were analyzed (364 in the p-SLR group and 67 in the non-SLR group). No difference in the 30-day incidence of SLL was observed between the two groups. The 30-day incidence of SLB (1.1% vs. 6.0% in the p-SLR and non-SLR groups, respectively) was significantly lower in the p-SLR group. These results were confirmed by PSM analysis. CONCLUSION Partial staple line reinforcement with synthetic buttressing material does not reduce the 30-day incidence of SLL. Although our analysis showed a significant reduction in the 30-day incidence of SLB in the p-SLR group, this result should be interpreted with caution.
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Affiliation(s)
- Christoph Eckharter
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Nickolaus Heeren
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Martin Sykora
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Department of Surgery, Nidwalden Hospital, Stans, Switzerland
| | - Julia Mühlhäusser
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Nathalie Lottenbach
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Andreas Scheiwiller
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jürg Metzger
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jörn-Markus Gass
- Department of General and Visceral Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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6
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Highet A, Johnson EH, Bonham AJ, Hutton DW, Zhou S, Thalji AS, Ghaferi AA. Cost-effectiveness of Staple Line Reinforcement in Laparoscopic Sleeve Gastrectomy. Ann Surg 2023; 277:121-126. [PMID: 34029226 DOI: 10.1097/sla.0000000000004950] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy. SUMMARY OF BACKGROUND DATA Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is staple-line reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy. METHODS Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Quality-adjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed. RESULTS A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts ( P = 0.8841); 0.45% compared with 0.59% for minor bleed ( P < 0.0001); and 0.24% compared with 0.26% for leak ( P = 0.4812). Median cost for a major bleed was $5552 ($3287, $16,817) and $2406 ($1861, $3484) for a minor bleed. Median leak cost was $9897 ($4589, $21,619) and median cost for patients who did not experience a bleed, leak, or other serious complication was $1908 ($1712, $2739). Mean incremental cost of reinforced stapling compared with standard was $819.60/surgery. Net QALY gain with reinforced stapling compared with standard was 0.00002. The resultant incremental cost-effectiveness ratio was $40,553,000/QALY. One-way and probabilistic sensitivity analyses failed to produce a value below $150,000/QALY. CONCLUSIONS Compared with standard stapling, reinforced stapling reduces minor postoperative bleeding but not major bleeding or leaks and is not cost-effective if routinely used in laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Alexandra Highet
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Emily H Johnson
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Aaron J Bonham
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - David W Hutton
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
- College of Engineering, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and innovation, University of Michigan, Ann Arbor, Michigan
| | - Shuhao Zhou
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Ameen S Thalji
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
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7
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Aboueisha MA, Freeman M, Allotey JK, Evans L, Caposole MZ, Tatum D, Levy S, Baker JW, Galvani C. Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database. Surg Endosc 2022; 37:3090-3102. [PMID: 35927350 DOI: 10.1007/s00464-022-09452-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. METHODS The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days. RESULTS A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). CONCLUSIONS Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.
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Affiliation(s)
- Mohamed A Aboueisha
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Meredith Freeman
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Jonathan K Allotey
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Leah Evans
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Michael Z Caposole
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Danielle Tatum
- Department of Surgery, Tulane University, New Orleans, LA, 70112, USA
| | - Shauna Levy
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - John W Baker
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA
| | - Carlos Galvani
- Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, 1430 Tulane Ave., Mailbox #8622, New Orleans, LA, 70112, USA.
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Iannelli A, Chierici A, Castaldi A, Drai C, Schneck AS. Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy. Obes Surg 2022; 32:2605-2610. [PMID: 35696051 DOI: 10.1007/s11695-022-06152-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding. METHODS Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance. RESULTS One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5 days, p < 0.001). CONCLUSIONS Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.
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Affiliation(s)
- Antonio Iannelli
- Université Côte d'Azur, Nice, France.
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France.
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Andrea Chierici
- Service de Chirurgie Digestive, Centre Hospitalier d'Antibes Juan-Les-Pins, 107, av. de Nice, 06600, Antibes, France
| | - Antonio Castaldi
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Céline Drai
- Université Côte d'Azur, Nice, France
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, France
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, 97159, Pointe à Pitre, Guadeloupe
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Ahmed A, Morales-Conde S, Legrand M, Nienhuijs S, Himpens J, Jiao LR, Facy O. Clinical outcomes of pre-attached reinforced stapler reloads in bariatric surgery: A prospective case series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies. Langenbecks Arch Surg 2021; 406:1683-1690. [PMID: 33829311 PMCID: PMC8026176 DOI: 10.1007/s00423-021-02161-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/28/2021] [Indexed: 11/18/2022]
Abstract
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.
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11
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Efficacy of Staple Line Reinforcement With Omentopexy During Laparoscopic Sleeve Gastrectomy on Postoperative Complications: Experience of a Single Center. Surg Laparosc Endosc Percutan Tech 2020; 31:181-187. [PMID: 32941357 DOI: 10.1097/sle.0000000000000863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the protective effects of staple line reinforcement with omentopexy during laparoscopic sleeve gastrectomy on postoperative complications. MATERIALS AND METHODS A total of 3942 laparoscopic sleeve gastrectomy cases were included in the study. All the patients were divided into 3 groups: No reinforcement (NoSLR), staple line reinforcement with fibrin glue (SLR-FG), and staple line reinforcement with omentopexy (SLR-O). Demographic data and perioperative characteristics of the groups were analyzed retrospectively. Among these, age, sex, preoperative comorbidities, American Society of Anesthesiologists scores, body mass index, duration of operation, reoperation, complications, and Clavien-Dindo classification scores were recorded. RESULTS Age, sex, body mass index, comorbid diseases, American Society of Anesthesiologists, and Clavien-Dindo Classification scores were similar in all the groups. The overall complication rate was 3.0%. The overall minor and major complication rates were 1.7% and 1.3%, respectively. The mortality rate was 0.1% (4 patients). The most common postoperative complications were bleeding (0.9%) and leakage (0.5%). The incidence of leakage, bleeding, and twisted gastric sleeve rates were similar when compared between SLR-FG and NoSLR. In the SLR-O patients, the incidence of leakage, hemorrhage, and twist were significantly lower and the operation time was significantly longer when compared with the other groups. CONCLUSIONS The SLR-O technique, especially when performed by experienced surgeons, is a promising method for the prevention of postoperative leakage, bleeding, and twist complications with an acceptable increase in the duration of operation. Considering the limited effects of the SLR-FG technique, it was predicted that it would lose its popularity over time.
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12
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Surgical Outcomes, Health Care Utilization, and Costs Associated with Staple Line Buttressing Among Primary Sleeve Gastrectomy Patients. Obes Surg 2020; 30:4935-4944. [PMID: 32910406 PMCID: PMC7719115 DOI: 10.1007/s11695-020-04917-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 02/08/2023]
Abstract
Purpose Staple line buttressing is a method of reinforcing surgical staple lines using buttress materials. This study evaluated surgical outcomes, hospital utilization, and hospital costs associated with staple line buttressing among patients who underwent primary laparoscopic sleeve gastrectomy (PLSG) in the United States. Methods This was a retrospective cohort study using Premier Healthcare Database data from January 1, 2012 to December 31, 2017. Patients aged ≥ 18 years who underwent PLSG were selected and assigned to buttress or non-buttress cohorts based on the use of buttress material during their hospitalization for PLSG (index). Propensity score matching (PSM) was conducted to balance patient demographic and clinical characteristics between the cohorts. Generalized estimating equation models were used to compare the clinical and economic outcomes of the matched buttress and non-buttress users during the index hospitalization. Results A total of 38,231 buttress and 27,349 non-buttress patients were included in the study. After PSM, 24,049 patients were retained in each cohort. Compared with non-buttress cohort, the buttress cohort patients had a similar rate of in-hospital leaks (0.28% vs 0.39%; p = 0.160) and a lower rate of bleeding (1.37% vs 1.80%, p = 0.015), transfusion (0.56% vs 0.77%, p = 0.050), and composite bleeding/transfusion (1.57% vs 2.04%, p = 0.019). Total costs ($12,201 vs $10,986, p < 0.001) and supply costs ($5366 vs $4320, p < 0.001) were higher in the buttress cohort compared with the non-buttress cohort. Conclusions Staple line buttressing was associated with an improvement in complication rates for bleeding and transfusion. Total and supply costs were higher in the buttress cohort, necessitating further research into cost-effective buttressing materials. Electronic supplementary material The online version of this article (10.1007/s11695-020-04917-2) contains supplementary material, which is available to authorized users.
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Kim WJ, Lee CM, An L, Kim JH, Park S. Effect of Biologic Material Reinforcement on Surgical Anastomosis After Gastrectomy-A Pilot Study. Front Oncol 2019; 9:1184. [PMID: 31781494 PMCID: PMC6851234 DOI: 10.3389/fonc.2019.01184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/21/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Acellular dermal matrix is a biologic material derived from the skin of human cadaveric donors. It has been used successfully in the past to reduce complications in breast surgery and hernia repair. This investigation was aimed at assessing the feasibility of using acellular dermal matrix to support the anastomosis after gastrectomy with the aim of reducing anastomotic site leakage complications. Methods: Patients were randomly assigned to standard anastomotic reconstruction (control arm) or anastomotic reconstruction with acellular dermal matrix reinforcement (intervention arm). Surgical outcomes related to anastomotic complications were collected. Because actual anastomotic leaks found on imaging studies are infrequent and thus require a very high number of patient recruitment to detect statistically significant difference between the two groups, in this pilot investigation other clinical and laboratory measures that have been shown to correlate to or predict anastomotic leaks were also collected. Each surgical outcome was compared. Results: A total of 94 patients (intervention arm: 50, control arm: 44), were included in the analysis. Two patients in the control arm (4.55%) and one patient in the intervention arm (2.00%) experienced anastomotic leakage (p = 0.598), a difference without statistical significance. However, average postoperative C-reactive protein (CRP) levels and NUn scores, both of which have been shown to reflect likelihood of progressing to anastomotic leakage, were significantly lower for the intervention arm. The control arm showed an average CRP level of 128.77 mg/dL (SD: 97.08) while the intervention arm showed 77.38 mg/dL (SD: 49.08, p = 0.049). Conclusions: Leakage rate reduction with acellular dermal matrix reinforcement of anastomotic site was not detected in this investigation. However, postoperative inflammation levels and numerical predictors of anastomotic leakage development were significantly lower with acellular dermal matrix reinforcement of surgical anastomosis. This finding is worthy of further investigation, as reduction of inflammation with anastomotic site reinforcement is a novel finding, and more in-depth research may lead to discoveries on the physiologic role of the surgical anastomosis in post-gastrectomy patients. In addition, lower CRP and NUn scores for the intervention arm suggest potential for larger studies to detect reduction in clinical leak rates after acellular dermal matrix reinforcement.
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Affiliation(s)
- Won Jun Kim
- Korea University Medical Center, College of Medicine, Seoul, South Korea
| | - Chang Min Lee
- Department of Surgery, Korea University Medical Center, Ansan Hospital, Ansan, South Korea
| | - Liang An
- Korea University Medical Center, College of Medicine, Seoul, South Korea
| | - Jong-Han Kim
- Department of Surgery, Korea University Medical Center, Guro Hospital, Seoul, South Korea
| | - Sungsoo Park
- Department of Surgery, Korea University Medical Center, Anam Hospital, Seoul, South Korea
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Erridge S, Payne CJ, Sodergren M. Novel clip applicator for minimally invasive surgery. Surg Endosc 2019; 33:2710-2718. [PMID: 31227900 PMCID: PMC6647405 DOI: 10.1007/s00464-019-06860-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/18/2019] [Indexed: 11/30/2022]
Abstract
Background Ligation clips are used ubiquitously throughout minimally invasive surgery for apposition of tissues. Their size limits their application beyond ligation of small tubular structures. A novel clip and clip applicator that allows for broad-area clamping and rotation has been developed by our team. The primary aim of this study is to provide preliminary data assessing tensile strength of the clip across apposed segments of bowel. Methods A comparative study evaluating the maximum load (N) held across two apposed tissues by (a) our novel broad-area clip and (b) a conventional commercial clip was performed. Two sections of porcine bowel were clamped together and the maximum load (N) was measured using a tensile strength material testing machine. A preliminary experiment comparing staple line leak pressures in a porcine model ± clip enforcement of staple line was also conducted. p < 0.05 determined statistical significance. Results Twenty-four samples (intervention = 15; control = 9) of porcine bowel annealed by surgical clips were tested. The mean maximum force withheld by the bowel and staples was greater for our novel clip design (2.043 ± 0.831 N) than the control clip (1.080 ± 0.466 N, p = 0.004). Ten staple line (intervention = 5; control = 5) pressures of porcine bowel were measured. There was no statistically significant difference between the leak pressures with clip reinforcement (84.8 mmHg; range 71.8–109.8 mmHg), or without (54.1 mmHg; range 26.3–98.9 mmHg). Conclusion These preliminary results suggest that our novel clip is able to withstand higher tensile force across tissues compared to a leading commercial clip. A small preliminary trial of effect on leak pressures demonstrated no statistical significance; however, increasing reliability of staple line deformation may be a clinically important finding. Whilst further iteration of product design and clinical testing is required, this product may occupy an important clinical niche through staple line reinforcement, enterotomy closure and other applications.
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Affiliation(s)
- Simon Erridge
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Christopher J Payne
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, USA
| | - Mikael Sodergren
- Academic Surgical Unit, Division of Surgery, Department of Surgery & Cancer, Imperial College London, 10th Floor QEQM, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
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15
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Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review. Surg Endosc 2019; 34:396-407. [PMID: 30993513 PMCID: PMC6946737 DOI: 10.1007/s00464-019-06782-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Michel Gagner
- Department of Surgery, Hopital du Sacré Coeur, 315 Place D’Youville, Suite 191, Montréal, QC H2Y 0A4 Canada
- Herbert Wertheim School of Medicine, Florida International University, Miami, FL USA
- Westmount Square Surgical Center, Westmount, QC Canada
| | - Paul Kemmeter
- Department of Surgery, Mercy Health Saint Mary’s, 2060 E Paris Ave SE #100, Grand Rapids, MI USA
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Zafar SN, Felton J, Miller K, Wise ES, Kligman M. Staple Line Treatment and Bleeding After Laparoscopic Sleeve Gastrectomy. JSLS 2019; 22:JSLS.2018.00056. [PMID: 30607100 PMCID: PMC6305063 DOI: 10.4293/jsls.2018.00056] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background and Objectives: Staple line treatment during laparoscopic sleeve gastrectomy (LSG) remains a controversial issue among bariatric surgeons. The objective of this study was to compare rates of postoperative bleeding (POB) among various methods of staple line reinforcement. Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 dataset was queried for patients undergoing an LSG. Patients were stratified by staple line treatment groups—no treatment (NT), suture oversewing (OVERSEW), buttressing by a commercial product (BUTTRESS), and both buttress and oversew (COMBINATION). The primary outcome was POB. Multivariable logistic regression was used to compare POB rates among the treatment groups. Results: In the 98,142 LSG patients meeting selection criteria, 623 (0.63%) patients had POB and 181 (0.18%) required reoperation. POB occurred in 0.80% for the NT group, 0.68% for the OVERSEW group, 0.57% for the BUTTRESS group, and 0.55% for the COMBINATION group. On multivariable analyses, all treatment groups were less likely to have POB compared with the NT group—OVERSEW (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.54–0.98), BUTTRESS (OR 0.70, 95% CI 0.57–0.84), and COMBINATION (OR 0.66, 95% CI 0.50–0.89) (all P < .01). Subset analysis revealed no difference between BUTTRESS and OVERSEW (OR 0.95, 95% CI 0.71–1.26, P = .71). Conclusions: Relative to an NT staple line, the use of OVERSEW or BUTTRESS can decrease the rates of POB by up to 30%. The use of these techniques should be strongly considered by the bariatric surgeon.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jessica Felton
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Kaylie Miller
- School of Medicine, University of Maryland, Baltimore, Maryland
| | - Eric S Wise
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Mark Kligman
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Iannelli A, Treacy P, Sebastianelli L, Schiavo L, Martini F. Perioperative complications of sleeve gastrectomy: Review of the literature. J Minim Access Surg 2019; 15:1-7. [PMID: 29737316 PMCID: PMC6293679 DOI: 10.4103/jmas.jmas_271_17] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 04/09/2018] [Indexed: 02/06/2023] Open
Abstract
Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.
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Affiliation(s)
- Antonio Iannelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
- Inserm, U1065, Team 8 “Hepatic Complications of Obesity”, Nice, France
- University of Nice Sophia Antipolis, Nice, Francea
| | - Patrick Treacy
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Lionel Sebastianelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Luigi Schiavo
- Department of Cardio-Thoracic and Respiratory Science, University of Campania “Luigi Vanvitelli”, Naples, Italy
- IX Division of General Surgery, Vascular Surgery and Applied Biotechnology, Naples University Polyclinic, Naples, Italy
| | - Francesco Martini
- Digestive and Bariatric Surgery Unit, Joseph Ducuing Hospital, Toulouse, France
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18
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Debs T, Petrucciani N, Kassir R, Sejor E, Karam S, Ben Amor I, Gugenheim J. Complications after laparoscopic sleeve gastrectomy: can we approach a 0% rate using the largest staple height with reinforcement all along the staple line? Short-term results and technical considerations. Surg Obes Relat Dis 2018; 14:1804-1810. [PMID: 30316829 DOI: 10.1016/j.soard.2018.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe the results of a single center's experience with SG, revealing a low complication rate. OBJECTIVES The aim of the study was to analyze the short-term results of laparoscopic SG using exclusively black staples with staple-line reinforcement. SETTINGS University hospital, tertiary referral center for bariatric surgery. METHODS SG was performed in 434 consecutive patients from December 2014 to March 2017. A technique is described where all operations were performed with attention to avoiding strictures at the incisura angularis and not stapling near the esophagus at the angle of His. All the interventions were performed using black cartridges and staple-line reinforcement using bioabsorbable Seamguard. A prospective chart review was conducted to determine the occurrence of early complications. RESULTS Follow-up data were collected for all patients at 90 days postoperatively. A total complication rate of 4.4% was observed. No leaks occurred in any of the patients. One case of bleeding occurred that necessitated a surgical exploration, which found the origin of the bleeding to be a diaphragmatic vessel. The 90-day mortality rate was 0%. CONCLUSION SG can be performed with a low complication rate. Selection of the appropriate staple height and reinforcement of the staple line could play a major role in optimizing the results of SG.
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Affiliation(s)
- Tarek Debs
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France.
| | - Niccolo Petrucciani
- Division of Digestive Surgery and Liver Transplantation, UPEC University, Henri Mondor Hospital, Creteil, France
| | - Radwan Kassir
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Eric Sejor
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Sami Karam
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Imed Ben Amor
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Jean Gugenheim
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
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Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial. Ann Surg 2018; 268:762-768. [PMID: 30080735 DOI: 10.1097/sla.0000000000002892] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG). BACKGROUND There is no consensus on the best means of preventing SLCs after SG. METHODS This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC. RESULTS There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found. CONCLUSION The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.
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Souche R, de Jong A, Nomine-Criqui C, Nedelcu M, Brunaud L, Nocca D. [Complications after bariatric surgery]. Presse Med 2018; 47:464-470. [PMID: 29703571 DOI: 10.1016/j.lpm.2018.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bariatric surgery became consensual after the NIH consensus of 1991 and the appearance of laparoscopic approach. This type of operation has a functional role (improvement of quality of life, locomotion and digestive symptoms as gastro-esophageal reflux disease), a prevention role (increase in life expectancy, reduction of risk of cancer and cardiovascular disease) and a curative role (remission of diabetes mellitus, obstructive sleep apnea syndrome and arterial hypertension). The laparoscopic approach for bariatric surgery led to a major reduction of postoperative morbi-mortality. Types and rates of complications after bariatric surgery vary according to the procedure. The efficiency of each technique is closely related to its morbi-mortality rate. This concept explains the disparity concerning the choice of the adequate procedure for the patient according to the bariatric team. The risk/benefits balance evaluation must be analyzed case-by-case by each specialist of the multidisciplinary bariatric staff and explained to the patients before final decision. This preoperative period (6 to 12 months) is crucial to select good candidates for bariatric surgery and contributes to the reduction of postoperative complications. A multidisciplinary surveillance for life is mandatory to prevent and treat late complications of bariatric surgery.
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Affiliation(s)
- Regis Souche
- Université de Montpellier, CHRU de Montpellier, hôpital St-Éloi, département de chirurgie digestive A, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - Audrey de Jong
- PhyMedExp, Université de Montpellier, INSERM, CNRS, CHU de Montpellier, Département d'anesthésie-réanimation Saint-Eloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - Claire Nomine-Criqui
- Université de Lorraine, CHU de Nancy, hôpital de Brabois, service de chirurgie digestive, hépatobiliaire, endocrinienne et carcinologique, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
| | - Marius Nedelcu
- Clinique Saint-Michel, centre de chirurgie de l'obésité (CCO), avenue d'Orient, 83100 Toulon, France
| | - Laurent Brunaud
- Université de Lorraine, CHU de Nancy, hôpital de Brabois, service de chirurgie digestive, hépatobiliaire, endocrinienne et carcinologique, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
| | - David Nocca
- Université de Montpellier, CHRU de Montpellier, hôpital St-Éloi, département de chirurgie digestive A, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
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21
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Mercier G, Loureiro M, Georgescu V, Skalli EM, Nedelcu M, Ramadan M, Fabre JM, Lefebvre P, Nocca D. Surgical glue in laparoscopic sleeve gastrectomy: An initial experience and cost-effectiveness analysis. J Eval Clin Pract 2017; 23:614-619. [PMID: 28322488 DOI: 10.1111/jep.12685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 10/28/2016] [Accepted: 10/31/2016] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Gregoire Mercier
- Department d'Information Médicale, CHU de Montpellier, Montpellier, France.,UMR LAMETA, Université de Montpelier, Montpellier, France
| | - Marcelo Loureiro
- Departamento de Biotecnologia, Universidade Positivo, Curitiba, Brazil.,Université Montpellier 1, Montpellier, France.,CHU de Montpellier, Montpellier, France
| | - Vera Georgescu
- Department d'Information Médicale, CHU de Montpellier, Montpellier, France
| | | | | | | | - Jean Michel Fabre
- Université Montpellier 1, Montpellier, France.,CHU de Montpellier, Montpellier, France
| | - Patrick Lefebvre
- Université Montpellier 1, Montpellier, France.,CHU de Montpellier, Montpellier, France
| | - David Nocca
- Université Montpellier 1, Montpellier, France.,CHU de Montpellier, Montpellier, France
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22
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Etiology of Leaks Following Sleeve Gastrectomy: Current Evidence. Surg Laparosc Endosc Percutan Tech 2017; 27:119-122. [DOI: 10.1097/sle.0000000000000400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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23
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Nedelcu M, Manos T, Gagner M, Eddbali I, Ahmed A, Noel P. Cost analysis of leak after sleeve gastrectomy. Surg Endosc 2017; 31:4446-4450. [PMID: 28378080 DOI: 10.1007/s00464-017-5495-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG. SETTING Private hospital, France. METHODS A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed. RESULTS Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€). CONCLUSIONS Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.
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Affiliation(s)
- Marius Nedelcu
- Centre Hospitalier Universitaire Montpellier, University Hospital of Montpellier, Montpellier, France. .,Digestive Surgery, University Hospital of Montpellier, 80, Avenue Augustin Fliche, 34295, Montpellier, France.
| | | | | | - Imane Eddbali
- The American Surgecenter, Abu Dhabi, United Arab Emirates
| | - Ahmed Ahmed
- St Mary's Hospital, Imperial College London, London, UK
| | - Patrick Noel
- The American Surgecenter, Abu Dhabi, United Arab Emirates
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Chivot C, Rebibo L, Robert B, Dhahri A, Regimbeau JM, Yzet T. Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:758-765. [PMID: 28330791 DOI: 10.1016/j.soard.2017.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING University hospital, France, public practice. MATERIAL AND METHODS This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.
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Affiliation(s)
- Cyril Chivot
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Lionel Rebibo
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Brice Robert
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France; Jules Verne University of Picardie, Amiens, France; Clinical Research Center, Amiens University Hospital, Amiens, France.
| | - Thierry Yzet
- Department of Radiology, Amiens University Hospital, Amiens, France
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Five-year results of laparoscopic sleeve gastrectomy for the treatment of severe obesity. Surg Endosc 2016; 31:3251-3257. [DOI: 10.1007/s00464-016-5355-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/12/2016] [Indexed: 12/15/2022]
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