Staple-line leak post primary sleeve gastrectomy. A two patient case series and literature review

The Effects of Laparoscopic Sleeve Gastrectomy on Body Mass Index (BMI) and Glycated Hemoglobin (HbA1c) Levels

Background and significance Bariatric surgery is an effective surgical intervention for weight loss and metabolic improvement. Articles tackling obesity and bariatric surgery with its preoperative preferences and postoperative findings are needed. From that stance, we aim to accurately document the impact of bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), on body mass index (BMI) and glycated hemoglobin (HbA1c) levels. Patients and methods We present a retrospective cohort study conducted on 111 LSG patients from a total of 1633 patients who underwent bariatric surgery from January 23, 2018, to December 31, 2019, at King Saud University Medical City in Riyadh, Saudi Arabia. Patients were divided into three groups: nondiabetics, prediabetics, and diabetics. For each group, demographic characteristics as well as preoperative and postoperative BMI and HbA1c values were collected. Results The mean patient age was 41.35±11.8 years, with 56.8% being female. Our analysis showed that BMI values for all three groups had a significant and nearly similar overall decrease in value postoperatively (mean difference: 14.43, p<0.001). HbA1c levels also significantly improved, with the largest reduction seen in the diabetic group (from 8.7±1.5 to 6.6±1.4, p<0.001), followed by the prediabetic group (from 5.9±0.2 to 5.4±0.3, p<0.001) and the nondiabetic group (from 5.4±0.1 to 5.2±0.3, p=0.003). Conclusion LSG leads to significant improvements in BMI and HbA1c levels. Postoperatively, diabetic patients showed the greatest reduction in HbA1c percentage, supporting LSG's role in enhancing metabolic health.

Use of Indocyanine Green to Detect Intraoperative Staple-Line Leaks in Robotic Bariatric Surgery: An Observational Cohort Study

Background Bariatric surgeries aid weight loss in patients with morbid obesity, yet staple-line leaks pose safety concerns. Multiple methods are used to help identify these links. Intraluminal indocyanine green (ICG) has been shown to be useful in other applications, and its use in robotic bariatric surgeries is underexplored. Objective The primary objective of this research project was to demonstrate the usage of intraluminal ICG in detecting staple-line leaks during robotic sleeve gastrectomy and robotic gastric bypass. Settings The research was conducted at Bronxcare Health System between June 2022 and June 2023. Methods We studied 150 consecutive participants undergoing robotic sleeve gastrectomy or robotic gastric bypass. Intraluminal ICG was used in each case in order to identify leaks. Data on comorbidities, detected intraoperative leaks, and detected postoperative leaks were collected. Results Out of the 150 patients who underwent robotic bariatric surgeries (139 for sleeve gastrectomy and 11 for gastric bypass), four cases (two for each procedure) were identified with intraoperative leaks using ICG, resulting in an overall 2.66% incidence rate. In those four patients with intraoperative leaks, reinforcing sutures and a drain were placed. Following the surgeries, none of the patients had radiologic or clinical leaks identified. Conclusions Intraluminal ICG presents a novel approach for detecting staple-line leaks in robotic bariatric surgery. Future studies can be done to look at a larger series of patients and compare leak detection rates between ICG and other methods.

Does Omentopexy Make a Difference in Laparoscopic Sleeve Gastrectomy for Obesity Treatment? A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database

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.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

The Impact of Drain and Reinforcement on the Outcomes of Bariatric Surgery: A Prospective Study

Purpose We aimed to investigate the impact of reinforcement and abdominal drains on the outcome of laparoscopic sleeve gastrectomy (LSG). Methods The present study was a prospective study that included obese patients scheduled to undergo LSG. Patients were assigned to receive drain, reinforcement, or both according to the surgeon's preference and followed up for one month after surgery. The present study's primary outcome was the identification of the association between intraoperative drain/reinforcement and the incidence of postoperative complications. Results A total of 125 (20.3%) patients received intraoperative drains. The proportion of postoperative morbidity was comparable between the drain and non-drain groups (3.2% versus 1.6%; p = 0.25). Patients in the drain group had similar incidence of blood transfusion (2.4% versus 1.7% in non-drain group; p = 0.43) and postoperative leakage (0.8% versus 0.2% in non-drain group; p = 0.36). The incidences of blood transfusion (p = 0.56) and reoperation (p = 0.98) were comparable between the drain and non-drain groups. There were no statistically significant differences between the drain and non-drain groups regarding postoperative mortality and wound infection (p > 0.05). On the other hand, 440 (71.3%) patients received reinforcement. The proportion of postoperative morbidity was comparable between the reinforcement and non-reinforcement groups (1.6% versus 2.8%, p = 0.07). Patients in the reinforcement group were less likely to develop postoperative bleeding (0.7% versus 4% in the non-reinforcement group; p = 0.004), while no significant difference was detected in terms of postoperative leakage (p = 0.33) and in-hospital mortality. Conclusion In conclusion, abdominal drainage did not reduce the complications of LSG patients. Reinforcement has some role in controlling the bleeding but not leaks. Both techniques did not significantly impact the mortality rate. In the future, additional, large randomized trials are needed to examine the gastrointestinal-related quality of life.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

The effects of bariatric surgery on dyslipidemia and insulin resistance in overweight patients with or without type 2 diabetes: a systematic review and network meta-analysis

Obesity has become an epidemic in several regions globally; it may lead to cardiovascular diseases, diabetes, and dyslipidemia. Despite many therapies, all bariatric procedures fail in some patients. There is a lack of literature comparing treatment effects on specific metabolic indexes. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for relevant articles. GeMTC and R software were used to perform a network meta-analysis, draw forest plots, investigate the possibility of statistical heterogeneity, generate I² statistics, rank probabilities, and evaluate relative effects of surgical procedures. All analyses were based on a Bayesian consistency model. We included 35 randomized controlled trials, comprising 2198 individuals and 13 interventions. For patients with high insulin resistance, single-anastomosis (mini-) gastric bypass (SAGB) and sleeve gastrectomy (SG) may be effective options, with mean differences (95% confidence intervals [CIs]) of -4.45 (-9.04 to -.34) and -4.23 (-6.74 to -2.22), respectively, compared with control groups. For patients with severe dyslipidemia, in addition to SAGB and SG, duodenal switch (DS) may be an effective surgery, with mean differences (95% CIs) of -.97 (-1.39 to -.55), -1.98 (-3.76 to -.19), .53 (.04 to 1.04), and -.94 (-1.66 to -.16) compared with control groups in terms of triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) concentrations, respectively. In adult overweight patients with or without diabetes, SAGB and SG are most effective at ameliorating insulin resistance. SAGB, Roux-en-Y gastric bypass + omentectomy, and DS are useful for reducing triglycerides, total cholesterol, and LDL-C. SG + omentectomy elevates HDL-C concentrations best. Adjustable gastric band and biliopancreatic diversion may not control insulin resistance or dyslipidemia well.

Laparoscopic Sleeve Gastrectomy with Omentopexy: Is It Really a Promising Method?-A Systematic Review with Meta-analysis

Purpose

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedure worldwide. Omentopexy during LSG is a novel variation of this well-established technique. There are no clear conclusions on indications for this procedure, safeness, and effects of such a method. We aimed to compare the outcomes of laparoscopic sleeve gastrectomy (LSG) with omentopexy (OP) and without omentopexy.

Materials and Methods

We searched the Medline, EMBASE, and Scopus databases up-to June 2020. Full-text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

Results

Of initial 66 records, only 4 studies (N = 1396 patients) were included in the meta-analysis. Our findings showed that LSG with omentopexy had significantly lowered overall morbidity compared to LSG without omentopexy (RR = 0.38; 95% CI [0.15, 0.94]; p=0.04). Gastric leakage rate (RR = 0.17; 95% CI [0.04, 0.76]; p = 0.02) was also significantly lower in LSG with omentopexy. There were no significant differences between groups in length of hospital stay.

Conclusions

Our meta-analysis showed that LSG with omentopexy may be a feasible procedure for decreasing morbidity and gastric leak rate. However, despite promising results, the procedure needs to be researched more in randomized controlled studies to draw solid conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05327-8.

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.

Assessment of a novel stapler performance for laparoscopic sleeve gastrectomy

BACKGROUND

Optimal stapler selection during laparoscopic sleeve gastrectomy requires careful balance between tissue compression, hemostasis, and mechanical integrity. Junctions along a staple line can further increase the risks of technical or mechanical staple line failures. The aim of this study was to compare two commonly utilized laparoscopic linear gastrointestinal staplers (Ethicon, Medtronic) with a novel linear stapler (Titan) designed to perform a sleeve gastrectomy with a single stapler firing.

METHODS

Excised gastric remnants from laparoscopic sleeve gastrectomy were utilized and tissue thickness was measured from fundus to antrum. An optimized experimental staple line was then created. The greater curve remnant was insufflated to determine the staple line burst pressure and location. The doubly stapled (clinical and experimental) gastric specimen underwent staple analysis for junctional location, malformation, and height.

RESULTS

The Titan stapler withstood a significantly higher burst pressure than both Ethicon and Medtronic linear cutting staplers. While the Medtronic and Ethicon staplers had a similar percentage of staples in junctions, the Titan stapler has no junctions. In considering the formation of all staples outside of junctions, the Medtronic and Titan staplers had no difference in percentage of malformed staples, while the Ethicon stapler had a significantly higher percentage. Additionally, there were no differences in mismatch between staple height and tissue thickness between experimental groups.

CONCLUSIONS

The Titan stapler conveys the mechanical benefits of higher burst pressure with the advantage of single load functionality. This single staple load eliminates staple line junctions without sacrificing the integrity of staple formation.