Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

Incidence and Risk Factors of In-Hospital Gastrointestinal-Related Complications Following Bariatric Surgery: A Retrospective Nationwide Inpatient Sample Database Study

BACKGROUND

Obesity is associated with numerous serious physiological and psychological health problems. Bariatric surgery (BS) remains the most effective treatment for obesity, but early postoperative gastrointestinal complications may require additional surgical intervention. The objective of this study was to analyze gastrointestinal-related complications (GRCs) and their risk factors following BS, including sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), using a nationwide database.

METHODS

An analysis of the Nationwide Inpatient Sample data from 2010 to 2019 was conducted to compare patients following BS with versus without postoperative GRCs. Variables included demographics, hospital characteristics, length of stay, costs, comorbidities, and complications. Risk factors were identified through stepwise multivariate logistic regression.

RESULTS

Among 323,066 BS patients, 12,248 (3.79%) developed GRCs, with a decreasing trend observed over the study period. Common complications included gastrointestinal bleeding (1.37%), bowel obstruction (1.84%), and anastomotic issues (0.99%). Significant risk factors included advanced age, anemia (deficiency and chronic blood loss), cardiovascular conditions (heart failure, valve disease, peripheral vascular disorders), coagulation abnormalities, rheumatoid arthritis or collagen vascular diseases, drug abuse, electrolyte imbalances, neurological conditions, renal failure, non-bleeding peptic ulcer disease, and weight loss. Interestingly, liver disease emerged as a risk factor for GRCs after SG while acting as a protective factor for GRCs after RYGB.

CONCLUSION

Understanding the risk factors for GRCs after BS would allow for improved patient management and clinical outcomes.

Effectiveness of Tranexamic Acid in Reducing Hidden Blood Loss During Laparoscopic Sleeve Gastrectomy: A Randomized Clinical Trial

Background: Tranexamic acid (TXA), an antifibrinolytic agent, has demonstrated efficacy in reducing bleeding across various surgical procedures. However, its role in bariatric surgery remains underexplored. This study aimed to evaluate the effectiveness of TXA in mitigating hidden blood loss following laparoscopic sleeve gastrectomy (SG). Methods: A single-center, single-blind, randomized, controlled trial was conducted at the University Clinical Center, Medical University of Gdańsk, Poland, between July 2022 and June 2023. A total of 238 patients undergoing SG were randomized to receive either TXA or no pharmacological intervention. The primary outcome was hemoglobin concentration in abdominal drainage post-surgery. Secondary outcomes included total blood loss, drainage volume, the need for blood transfusion, and postoperative complications. Statistical analyses were conducted using intention-to-treat and per-protocol strategies. Results: A statistically significant reduction in hemoglobin concentration in abdominal drainage samples was observed in the TXA group (p = 0.011). No significant differences were found in total blood loss, drainage volume, necessity for blood transfusions, or extended hospital stay between groups. Conclusions: While TXA administration may reduce the hidden blood loss effect, its general clinical significance appears questionable. Nonetheless, intraoperative TXA may be beneficial for a selected patient group with multiple preoperative disorders and risk factors. Further research is necessary to comprehensively assess the risks and benefits of TXA administration in bariatric surgery.

Predictors and Trends of Hemorrhage After Bariatric Surgery Using Two Large National Datasets: A Retrospective Observational Study

INTRODUCTION

The National Inpatient Sample (NIS) is a comprehensive representative database for inpatient hospitalizations; the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database aggregates surgical outcomes from nationally accredited bariatric surgical programs. There has been no comparison of postoperative hemorrhage rates nor a comparison of predictors of hemorrhage between the two databases. The aim of this study was to compare trends and predictors of significant hemorrhage after bariatric surgery using two national databases.

METHODS

The core NIS files of the Healthcare Cost and Utilization Project and the MBSAQIP Participant Use Data Files from 2016 to 2021 were concatenated, and vertical sleeve gastrectomy and Roux-en-Y gastric bypass procedures were included. Trends in a 3-d postoperative hemorrhage requiring blood transfusion were derived from both datasets. Demographic, comorbidity, and other health factors were analyzed to construct multivariable logistic regression models.

RESULTS

Briefly, 204,866 and 1,029,979 patients were identified in the NIS and MBSAQIP, respectively, and 3-d inpatient blood transfusion rates were 0.48% and 0.64%. Anticoagulants, Black race, diabetes, and increased age were associated with higher risk of a blood transfusion in both datasets. Vertical sleeve gastrectomy had a lower transfusion risk than Roux-en-Y gastric bypass (NIS: odds ratio: 0.62; 95% confidence interval [0.53, 0.71], P < 0.05; MBSAQIP: odds ratio: 0.52 [0.49, 0.55], P < 0.05). The NIS reported consistently lower annual 3-d transfusion rates relative to the MBSAQIP.

CONCLUSIONS

Health care professionals should be aware of the associated risk factors for blood transfusion after bariatric surgery. Most blood transfusions occurred during the initial hospitalization.

Demographic Factors Associated with Postoperative Complications in Primary Bariatric Surgery: A Rapid Review

BACKGROUND

Bariatric surgery is highly effective for the management of severe obesity, but its safety profile is not completely understood. This review aimed to synthesise evidence linking demographic factors to postoperative complications and mortality following primary bariatric surgery.

METHODS

We searched Medline for observational studies of adult patients linking demographic factors to postoperative complications of primary bariatric surgery published from 2017 to 2022. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and pooled using random effect meta-analysis. Heterogeneity was quantified using the I2 statistic and tested for statistical significance using the Q-statistic. Sensitivity analyses were used to explore potential sources of heterogeneity.

RESULTS

A total of 71 observational studies (69 cohort, 2 case-control) were reviewed and appraised. Older age was consistently associated with increased risks of postoperative mortality (RR = 2.62, 95% CI 1.63-4.23, I2 = 42.04%), serious complications (RR = 1.76, 95% CI 1.09-2.82, I2 = 93.24%), anastomotic leak (RR = 1.64, 95% CI 1.04-2.58, I2 = 61.09%), and haemorrhage (RR = 1.44, 95% CI 1.07-1.94, I2 = 45.25%). Male sex was associated with increased anastomotic leak (RR = 1.39, 95% CI 1.04-1.87, I2 = 72.36%). Sensitivity analyses did not identify sources of bias. Socioeconomic factors, including Black/African American race, low financial status, and marital status (mixed results), were linked to higher complication risks in some studies.

CONCLUSIONS

Older age and certain demographic factors (male sex, Black/African American race, low financial status, marital status) were associated with increased risks of postoperative complications following primary bariatric surgery.

Comparison of Postoperative Bleed Rates and Location of Bleed Between Vessel Sealing Devices after Laparoscopic Sleeve Gastrectomy

Background: Laparoscopic sleeve gastrectomy (SG) is a commonly performed bariatric procedure. At our institution, two vessel sealing devices, Thunderbeat® (Olympus) and Maryland LigaSure™ (Covidien) are utilized for intraoperative dissection. Methods: A retrospective review of all patients who underwent primary SG from July 2013 through August 2022 was performed to evaluate postoperative bleeding (POB) rates between the two devices. The primary outcome measured was POB as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with secondary outcomes including reoperation, source of bleed, and overall safety. Results: A total of 8157 underwent SG. Average BMI and age were 43.2 kg/m2 and 37.1 years, respectively. A total of 6600 (80.9%) were female. Thunderbeat® was utilized in 5143 (63%) cases and Maryland LigaSure™ was used in 3014 (37%) cases. There was no significant difference in overall bleeding between the Thunderbeat® (18/5143, .35%) and the Maryland LigaSure™ (19/3014, .63%; P = .0689). However, there was a difference noted when comparing reoperation for bleeding between Thunderbeat® (9/5143, .17%) and Maryland LigaSure™ (13/3014, .43%; P = .0291). Furthermore, the location of bleeding in the reoperations was more common from the cut edge of the mesentery compared to the staple line with the Maryland LigaSure™ versus the Thunderbeat® (P = .038). Conclusions: The Thunderbeat® device is comparatively more hemostatic than the Maryland LigaSure™ for SG. The location of postoperative bleed may be related to vessel sealing devices used.

Predictors of postoperative bleeding after minimally invasive bariatric surgery

BACKGROUND

Minimally invasive bariatric surgeries provide effective weight loss with fewer complications. However, postoperative bleeding remains a significant concern due to its potential for serious morbidity and mortality. This study aimed to identify factors predicting postoperative bleeding following laparoscopic and robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

METHODS

We analyzed patients who underwent SG and RYGB using the MBSAQIP database from 2015 to 2021. Four multivariate logistic regression analyses were conducted to investigate the relationship between postoperative bleeding and 24 independent factors for laparoscopic SG (lapSG), robotic SG (rSG), laparoscopic RYGB (lapRYGB), and robotic RYGB (rRYGB).

RESULTS

We analyzed 659,294 lapSG, 53,548 rSG, 267,171 lapRYGB, and 22,492 rRYGB patients. In lapSG, the most significant factors included anticoagulation (OR 3.76; 95% CI 3.13-4.51), renal insufficiency (OR 2.06; 95% CI 1.37-3.09), history of DVT (OR 1.87; 95% CI 1.23-2.85), history of PE (OR 1.69; 95% CI 1.04-2.76, and BMI ≤ 40 (OR 1.22; 95% CI 1.09-1.38). In the rSG group, anticoagulation (OR 4.95; 95% CI 2.83-8.66), COPD (OR 2.80; 95% CI 1.29-6.05), and hyperlipidemia (OR 1.90; 95% CI 1.29-6.05) were significant factors. In lapRYGB, the most significant factors included anticoagulation (OR 3.68; 95% CI 3.11-4.35), renal insufficiency (OR 1.60; 95% CI 1.04-2.44), history of DVT (OR 1.70; 95% CI 1.09-2.07), cardiac stent (OR 1.51; 95% CI 1.09-2.07), and BMI ≤ 40 (OR 1.16; 95% CI 1.03-1.29). For rRYGB, anticoagulation (OR 4.69; 95% CI 2.86-7.70), history of PE (OR 4.28; 95% CI 1.53-12.00), and cardiac stent (OR 2.15; 95% CI 0.06-4.34) were significant.

CONCLUSION

Preoperative anticoagulation, renal insufficiency, history of DVT and PE, a cardiac stent, and BMI ≤ 40 are associated with an increased risk of postoperative bleeding. The predictive factors were consistent across laparoscopic and robotic approaches in SG and RYGB procedures.

Endoscopic management of complications after sleeve gastrectomy: a narrative review

Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure globally due to its technical simplicity and proven efficacy. However, complications following SG, including bleeding, leakage, fistulas, stenosis, gastroesophageal reflux disease (GERD), and hiatal hernia (HH), remain a significant concern. Endoscopic interventions have emerged as valuable minimally invasive alternatives to traditional surgical approaches for managing these complications. This review aims to provide a comprehensive overview of the endoscopic management strategies available for addressing the various complications encountered after SG, emphasizing their critical role in optimizing patient outcomes.

Efficacy of Omentopexy on Complications of Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed type of bariatric surgery. Early complications of LSG include bleeding, leakage, pulmonary embolism, and surgical site infections. Most surgeons try to implement preventive methods, such as omentopexy. Staple line-imbrication, which has a difficult learning curve, often prevents complications. This study aimed to evaluate the effect of omentopexy on patients with imbricated LSG.

MATERIAL AND METHODS

The study applied a retrospective data analysis design to patients who underwent LSG between 2020 and 2023. All patients' staple lines were imbricated, and patients were then divided into two groups: omentopexy group and control group. Patients' demographic features, such as age, gender, height, weight, body mass index(BMI), bleeding, leakage, and reoperations, were recorded and examined retrospectively.

RESULTS

A total of 1356 patients were included in the study (540 in omentopexy, 816 in control), of which the mean age was 37.9 ± 10.5 years, 82.3% were women, and mean BMI was 40.9 ± 5.8 kg/m2. The mean bleeding rate was 1.0% (1.3-0.7%), the mean leakage rate was 0.2% (0.2-0.2%, respectively), and the mean reoperation rate was 0.6% (0.7% and 0.5%, respectively). No statistically significant differences were observed.

CONCLUSION

Omentopexy is a technique that is widely used to prevent staple line complications. According to our study, omentopexy applied to an imbricated stapler line increased the operation time but did not affect bleeding or leakage ratios. This is the first study to evaluate the effect of omentopexy on imbricated staple lines. The findings of the study indicate that omentopexy has no additional benefit on early complications when using staple-line imbrication.

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety

BACKGROUND

The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH).

MATERIAL AND METHODS

This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery.

RESULTS

One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55-0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication.

CONCLUSION

MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates

BACKGROUND

Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days.

OBJECTIVES

Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis.

SETTING

University Hospital.

METHODS

Between 2012-2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018-2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed.

RESULTS

A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively.

CONCLUSIONS

Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

Single Anastomosis Duodeno-Ileal bypass (SADI-S) as Primary or Two-Stage Surgery: Mid-Term Outcomes of a Single Canadian Bariatric Center

PURPOSE

Compare primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and two-stage SADI after sleeve gastrectomy (SG) in terms of weight loss, reduction/remission of comorbidities, and morbidity.

METHODS

Retrospective study including 179 patients treated laparoscopically between 2016 and 2020. A 50Fr bougie was used for the SG in the primary SADI-S (group 1) and 36/40Fr for the two-stage procedure (group 2). The duodeno-ileal anastomosis was performed at 250 cm from the ileocecal valve and at least 2 cm after the pylorus.

RESULTS

Mean age was 44.1 years old, and there were 148 women and 31 men. There were 67 (37.4%) patients in group 1 and 112 (62.6%) in group 2, with 67% completing the 4-year follow-up. Mean preoperative body mass index (BMI) was 51.1 kg/m2 and 44.6 kg/m2 for groups 1 and 2, respectively. Preoperative comorbidities were obstructive sleep apnea, hypertension, type 2 diabetes, and dyslipidemia in 103 (57.5%), 93 (52%), 65 (36.3%), and 58 (32.4%) of cases. At 4 years postoperatively, excess weight loss (EWL) was 67.5% in group 1 and 67% in group 2 (p = 0.1005). Both groups had good comorbidity remission rates. Early postoperative morbidity rate was 10.4% in group 1 and 3.6% in group 2. In group1, there were mostly postoperative intra-abdominal hematomas managed conservatively (n = 4). Two revisional surgeries were needed for duodeno-ileal anastomosis leaks. Postoperative gastroesophageal reflux disease (GERD), daily diarrhea, vitamin, and protein levels were similar in both groups.

CONCLUSION

Both types of strategies are efficient at short and mid-term outcomes. Preoperative criteria will inform surgeon decision between a primary and a two-stage strategy.

Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients

BACKGROUND

There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation.

METHODS

This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020-July 2022) to those who did not (March 2011-March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation.

RESULTS

TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death.

CONCLUSIONS

This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.

Effect of Tranexamic Acid on Postoperative Bleeding in Sleeve Gastrectomy: a Randomized Trial

PURPOSE

Research on the timing and efficacy of tranexamic acid (TXA) use for perioperative bleeding in bariatric surgery is lacking. To evaluate the effects of TXA use on clinical outcomes in laparoscopic sleeve gastrectomy (LSG) by comparing TXA use at the beginning of induction with TXA use at the end of surgery and placebo use.

MATERIALS AND METHODS

Between February 2022 and August 2022, 177 patients were randomized into three groups: TXA administered at the beginning of induction (TXAI), TXA administered at the end of surgery (TXAP), and placebo groups. Preoperative and postoperative care was standardized, and all patients received LSG. Analyzed using ANOVA, Mann-Whitney U test, and Student's t-test.

RESULTS

No significant difference was observed between the groups in terms of operative time and blood loss. There were significantly fewer intraoperative bleeding points in the TXAI group compared to the other groups (P < 0.05). Postoperative bleeding was significantly lower in the TXAI and TXAP groups compared to the placebo group (P < 0.05). Hemoglobin and CRP levels showed significant differences between the groups. TXA administration did not cause a significant decrease in coagulation values, and there were no cases of venous thromboembolism (VTE) during the follow-up period.

CONCLUSION

This study provides evidence that TXA administered during LSG is effective in reducing postoperative bleeding. No data were obtained regarding the superiority of TXA administration at the beginning of induction and at the end of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov with the registration code NCT05696951, 25 January 2023: https://www.

CLINICALTRIALS

gov/study/NCT05696951 .

Postoperative Stomach Volvulus and Pancreatitis Following a Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy is the most common bariatric surgery performed to promote weight loss and improve obesity-related comorbidities. As the number of patients undergoing sleeve gastrectomy increases, so does the prevalence of complications. It is crucial to recognize both common and unusual complications of sleeve gastrectomy to properly diagnose and manage them. We present a unique case of gastric outlet obstruction not visualized on initial imaging and acute pancreatitis following a sleeve gastrectomy. We recommend performing an endoscopy and ordering serum lipase levels in a patient with negative CT scans but persistent postoperative nausea, vomiting, and abdominal pain. The management of postoperative gastric outlet obstruction includes supportive care, balloon dilation of the stenotic area, or gastric bypass if symptoms persist.

Role of Tranexamic Acid (TXA) in Preventing Bleeding Following Sleeve Gastrectomy: a Systematic Review and Meta-analysis

BACKGROUND

Tranexamic acid (TXA) has drawn growing interest over the last decade for its benefit in optimizing post-operative bleeding, yet its role in bariatric surgery is poorly understood.

METHODS

The medical librarian developed and executed comprehensive searches on September 28, 2022. The population of interest included adults who underwent elective bariatric surgery. The intervention was tranexamic acid administration while the comparison was placebo or standard peri-operative therapy. The primary outcome of interest was post-operative bleeding which was defined a priori.

RESULTS

A total of four studies were identified comprising of 475 patients. Of those, 207 (50%) received TXA at induction and all underwent laparoscopic sleeve gastrectomy (LSG). The majority of patients were female (n = 343, 80.7%) with ages ranging from 17 to 70 years of age and mean BMIs ranging from 37 to 56 kg/m². Post-operative bleeding after LSG ranged from 0 to 28% depending on bleed definition and TXA administration with no differences in venous thromboembolic events or mortality between groups. Meta-analysis of post-operative bleeding demonstrated a statistically significant benefit with TXA administration (OR 0.40; 95% CI 0.23-0.70; p = 0.001) for patients undergoing elective LSG.

CONCLUSIONS

Intravenous tranexamic acid at the time of laparoscopic sleeve gastrectomy is associated with a significant reduction of post-operative bleeding with no observed differences in thromboembolic events or mortality. Further high-quality studies are needed to better delineate the ideal bariatric population to receives TXA in addition to the optimal timing, dose, and duration of TXA therapy.

The Effect of Sizing Device Use During Laparoscopic Sleeve Gastrectomy on Rates of Postoperative Dehydration and Other 30-day Complications: An Analysis of the ACS-MBSAQIP Database

BACKGROUND

During laparoscopic sleeve gastrectomy (LSG), many surgeons use an intraoperative sizing device. However, the choice of intraoperative sizing device varies and the optimal choice or combination of sizing devices, such as a bougie or esophagogastroduodenoscopy (EGD), is not known. The purpose of this study was to determine if there is an association between the use of a sizing device or a combination of sizing devices on rates of dehydration, bleeding, and staple line leak following LSG.

MATERIALS AND METHODS

Patients between the ages of 18 to 80 who underwent elective LSG were identified using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP) database from 2015 to 2019. Postoperative outcomes, including rates of dehydration, bleeding, and staple line leak, were compared across 4 groups: those that utilized bougie and EGD (both), those that utilized only bougie (bougie only), those that utilized only EGD (EGD only), and those that did not utilize either sizing device (neither).

RESULTS

In all, 533,151 cases met the inclusion criteria. On univariate analysis, the bougie-only group experienced the highest rates of dehydration events. On multivariate analysis, the use of both sizing devices was associated with significantly lower odds of events related to dehydration versus bougie only (aOR 0.869, P =0.0002), and bougie only was associated with significantly higher odds of events related to dehydration versus EGD only (aOR 1.773, P =0.0006).The neither-sizing device group did not show any statistically significant differences in any of the comparisons.

CONCLUSIONS

Bougie use alone was associated with more dehydration-related complications, while EGD use demonstrated a protective effect. Not using a sizing device was associated with equivalent outcomes to all combinations of sizing devices. These findings highlight the need for the standardization of sizing devices during LSG and suggest that foregoing sizing devices may be a management option without early adverse sequelae.

Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis

BACKGROUND

Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing.

METHODS

MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors.

RESULTS

Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR.

CONCLUSIONS

Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.

Optimization of Surgical Time Through the Implementation of a Rational Protocol to Prevent Bleeding in Sleeve Gastrectomy

Introduction: Staple line oversewing (SLO) is a prophylactic alternative due to its low cost and its effect of decreasing the incidence and severity of bleeding complications in sleeve gastrectomy (SG). However, this approach significantly increases the surgical time and may be associated with stenosis. The study aims to identify whether its usage was sufficient to optimize the surgical time in patients whose screening for the risk of occult bleeding was negative. Materials and Methods: The study enrolled 103 patients. Having the systolic blood pressure goal of 140 mmHg, the staple line is checked for bleeding points, counting as follows: >5 bleeding points proceed to SLO, <5 bleeding points are managed using clips, and if no bleeding points are found, the procedure can be completed. Results: The bleeding test was positive in 79.6% of the cases and oversewing was necessary for 44.7% of the total. The bleeding test result was significant for the increased surgical time. The mean surgical time in SLO was 16.4% higher than in clipping. There was a significant difference in surgical time between SLO and clipping; however, no significant difference was identified between clipping and continuing the procedure without further measures. No postoperative complication related to staple line bleeding was identified. Discussion: In a scenario with limitations for the use of high-cost homeostatic agents, the stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time without significant added risks. Conclusion: A stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time.

Tranexamic acid effects in postoperative bleeding outcomes in laparoscopic sleeve gastrectomy: a controlled study

PURPOSE

To demonstrate through a controlled study whether the use of tranexamic acid in bariatric surgeries is effective for bleeding control.

METHODS

Prospective, comparative, and double-blind study performed with patients from 18 to 65 years old submitted to bariatric surgery. The selected patients received venous tranexamic acid (TXA) during the induction of anesthesia or not (CG). The anesthesia and thromboprophylaxis protocols were similar among the groups. For statistical analysis, the χ2 and analysis of variance tests were performed at a significance level of p < 0.05, using the statistical program SPSS 21.0®.

RESULTS

Sixty-one patients were included in the study, 31 in the control group and 30 in the TXA group (GTXA). In the intraoperative period, the bleeding volume was greater in the CG than in the GTXA. In the postoperative period, the tranexamic acid group had a higher value hematocrit, absence of surgical reoperations due to bleeding complications, and shorter hospitalization time than the control group.

CONCLUSIONS

The use of tranexamic acid was effective in reducing bleeding rates and of hospital stay length, in addition to demonstrating the clinical safety of its use, for not having been associated with any thromboembolic events.

Bariatric surgery: to bleed or not to bleed? This is the question

BACKGROUND

Bariatric surgery procedures are the most successful and durable treatment for morbid obesity. Hemorrhage represents a life-threatening complication, occurring in 1.3-1.7% of bariatric surgeries.

MATERIALS AND METHODS

We examined patients undergoing Bariatric Surgery from July 2017 to June 2020 (Group A) and those operated from July 2020 to June 2022 (Group B) in our Department. Starting from July 2020 we have implemented intraoperative measures to prevent postoperative bleeding, increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneal pressure of CO2 to 8 mmHg in the last 15 min of the operation.

RESULTS

The study gathered 200 patients divided into the two described groups. The mean age of Group A is 44 ± 8.49 and 43.73 ± 9.28. The mean preoperative BMI is 45.6 kg/m2 ± 6.71 for Group A and 48.9 ± 7.15 kg/m2 for Group B. Group A recorded a mean MAP of 83.06 ± 18.58 mmHg and group B a value of 111.88 ± 12.46 mmHg (p value < 0.05 and z-score is 4.15226 and the value of U is 13,900). We observed 9 cases of bleeding in group A, most of them being treated with medical therapy and transfusions; only 1 hemodynamically unstable patient underwent re-laparoscopy. We reported only 2 cases of bleeding in group B, one of which required blood transfusions.

CONCLUSION

From our study we can conclude that increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneum pressure of CO2 to 8 mmHg in the last 15 min of the operation led to a decrease in bleeding cases in group B and, most importantly, all the bleedings were easily controllable with medical therapy and/or transfusions. These measures allowed us to reduce postoperative bleeding.

Prospective Randomized Comparison of Linear Endostaplers During Laparoscopic Sleeve Gastrectomy

PURPOSE

The development of Laparoscopic Linear Endostaplers (LLES) is crucial in minimally invasive approaches in bariatric surgery, but there have been very few published studies comparing 6-row LLES in Laparoscopic Sleeve Gastrectomy (LSG). The objective of this study was to compare two 6-row LLES in LSG.

METHODS

A total of 60 patients were prospectively randomized to undergo LSG with either Medtronic Endo GIA™ Tri-Staple technology (MTS) or AEON ™ Endostapler(Lexington Medical) LLES. The measured parameters included patient demographics, comorbidity indices, LLES and specimen characteristics, postoperative symptoms, hospital stay, and total adverse events (AEs). Intraoperative bleeding was evaluated using five laparoscopic and corresponding endoscopic images of staple line before clip application, compared with a 1-5 Visual Analogue Scale (VAS), assessed by an independent bariatric surgeon who was blinded to the LLES used. Images of all cases were reviewed on the same day to increase test-retest reliability.

RESULTS

Both groups were similar in patient demographics. Compared to MTS, AEON LLES group had significantly lower bleeding VAS scores in 4/5 laparoscopic images (pre-pyloric: 1.7 ± 0.7 vs. 2.36 ± 0.76, p = 0.0007, mid-sleeve: 1.46 ± 0.62 vs. 1.86 ± 0.68, p = 0.019, proximal sleeve: 1.6 ± 0.77 vs. 2.0 ± 0.83, p = 0.038, gastro-esophageal junction: 1.43 ± 0.67 vs. 1.86 ± 0.77, p = 0.014) and 3/5 endoscopic images (pre-pyloric: 1.56 ± 0.56 vs. 2.36 ± 0.76, p = 0.006, incisura: 1.66 ± 0.54 vs. 2.0 ± 0.52, p = 0.021, mid-sleeve: 1.63 ± 0.49 vs. 2.0 ± 0.45, p = 0.005). There was no statistical difference in other parameters.

CONCLUSION

Both devices were equally safe and effective in terms of LLES and specimen characteristics, patient symptoms, hospital stay, and AEs. Bleeding VAS scores were significantly lower, favoring the AEON LLES.

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.

Effectiveness of prophylactic doses of tranexamic acid in reducing hemorrhagic events in sleeve gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric surgery in the world. Although it appears to be a safe treatment for obesity, it is still at risk of complications. The latest literature shows that postoperative bleeding occurs in 2-4% of cases, and up to 3% of cases requires reoperation for hemostasis. The aim of the study is to assess the effect of tranexamic acid (TXA) on hemorrhagic events and the reoperation rate in patients undergoing LSG.

METHODS

The study was designed as a retrospective analysis of patients undergoing LSG. We investigate the patients 6 months before and 6 months after introducing the prophylaxis doses of TXA into our bariatric protocol (non-TXA group vs TXA group).

RESULTS

Three hundred fourteen patients underwent LSG in a high-volume center from 2016 to 2017. After introducing TXA, a statistically significant reduction in the incidence of hemorrhage during surgery was observed (22.3% vs 10.8%, p = 0.006). There was a statistically significant reduction in the need for the staple line oversewing (10.2% vs 1.9%, p = 0.002). The mean operating time and the mean length of hospital stay were significantly higher in the non-TXA group than TXA group (63.1 vs 53.7 min, p < 000.1; 2.3 vs 2.1, p = 0.02). In both groups of patients, no venous thromboembolism or other complications occurred within 6 months after the surgery.

CONCLUSIONS

The prophylactic doses of TXA may be useful in reducing the hemorrhagic events during LSG. It may also shorten the length of hospital stay and the operating time.

Prediction Factors of Early Postoperative Bleeding after Bariatric Surgery

PURPOSE

Identifying the possible predictors of postoperative bleeding is advantageous to reduce healthcare costs and promote patients' recovery. The aim of this study was to determine early postoperative bleeding predictors after bariatric surgery.

MATERIALS AND METHODS

This retrospective study was conducted using data from 2260 patients who underwent bariatric surgery. We diagnosed early postoperative bleeding by the following symptoms: abdominal pain, hypotension, tachycardia, hematemesis, melena, decreased hemoglobin level, the need for at least two units of packed red blood cells (PRBCs) transfusion, and reoperation within the first 48 h after surgery.

RESULTS

Our results showed the odds of early postoperative bleeding in laparoscopic Roux-en-Y gastric bypass (LRYGB) were higher than in laparoscopic sleeve gastrectomy (LSG) (OR 3.49, 95% CI 1.79 to 6.80). In addition, prior intragastric balloon (IGB) (OR 3.14, 95% CI 1.18 to 8.34) and oral non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) (OR 5.91, 95% CI 1.79 to 20.63) were positively associated with the occurrence of postoperative bleeding. In contrast, there was an inverse relationship between staple line oversewing and the odds of postoperative bleeding (OR 0.18, 95% CI 0.04 to 0.81). After stratification data based on the type of the surgery, the positive association between IGB and the odds of bleeding was constant in the LRYGB group. In the LSG group, use of non-aspirin NSAIDs was linked to a higher incidence of postoperative bleeding, while oversewing of the staple line lowered the incidence of this event.

CONCLUSIONS

Our results demonstrated a positive association between type of procedure, history of IGB, and oral non-aspirin NSIADs use, as well as an inverse relationship between staple line oversewing and the odds of bleeding after bariatric surgery.

Stapler Malfunctions in Bariatric Surgery: An Analysis of the MAUDE Database

Background

Staple line leaks are a serious problem in bariatric surgery and a major cause of serious morbidity and mortality. Adverse events caused by medical devices are reported to the Food and Drug Administration which maintains the Manufacturer and User Facility Device Experience (MAUDE) database. We examined adverse stapler events reported to the MAUDE database, specifically with regards to bariatric surgery.

Methods

The MAUDE database was queried for adverse events caused by staplers between January 1, 2018 - December 31, 2020; events reported by Intuitive, Ethicon, and Medtronic/Covidien; and limited our search to "gastric bypass", "sleeve gastrectomy", "stapler malfunction" combined with each company.

Results

There were 883 adverse events reported for Medtronic, 353 for Ethicon, and 35 for Intuitive. Approximately 3.5 million staple reloads sold in the study period. The reported misfire rate for Medtronic was 0.04% and for Ethicon was 0.02%. Data for Intuitive was unavailable. The most common reported event for Medtronic was failure to fire (n = 349), followed by misfire (n = 186). For Ethicon, the most common event was failure to fire (n = 146), followed by mechanical problems (n = 27). The most common event with the Intuitive stapler was leak (n = 10) and bleeding from staple line (n = 8).

Conclusions

Stapler malfunction is a very rare event in metabolic and bariatric surgery. All of the major stapler producers have transitioned to powered staplers with excellent safety profiles. Open and honest reporting about stapler malfunction is essential to determine the true safety of these ubiquitous devices.

Surprising neutral effect of shorter staple cartridges in laparoscopic sleeve gastrectomy

BACKGROUND

Consensus agreements regarding laparoscopic sleeve gastrectomy (LSG) advise against using staple loads less than 1.5 mm in closed staple height. However, few data exist to support this recommendation. We hypothesized that using staples with a shorter closed height would actually decrease incidence of intraoperative and postoperative bleeding during LSG, while not increasing the incidence of leak.

METHODS

All LSG cases for a single institution from 1/1/2014 to 12/31/2019 were exported for analysis. Two cohorts were established: 1. 'Green/Blue' group was cases in which no white cartridges were used and 2. 'White' group was cases in which any white cartridges were used. Demographic variables, procedural characteristics, hospital length of stay, and postoperative outcomes were compared between groups.

RESULTS

The study populations included 1710 patients, 974 in the green/blue group and 736 in the white cartridge group. There were no significant differences in postoperative leak, bleed, stricture, readmission, or death while using white staple loads as compared with the standard combination of blue and green loads.

CONCLUSION

Using staples with a shorter closed height during LSG did not impact the postoperative bleeding or leak rate. The impact from selection of shorter staples to achieve more tissue compression may be limited.

The Choice of Gastric Bypass or Sleeve Gastrectomy for Patients Stratified by Diabetes Duration and Body Mass Index (BMI) level: Results from a National Registry and Meta-analysis

PURPOSE

To determine whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) should be the optimal choice in patients stratified by diabetes duration and body mass index (BMI) level.

METHODS

Classification tree analysis was performed to identify the influential factors for surgical procedure selection in real setting. Meta-analyses stratified by influential factors were conducted to compare the complete diabetes remission rates between SG and RYGB. The cost-effectiveness analysis was performed when results from meta-analysis remain uncertain.

RESULTS

Among 3198 bariatric procedures in China, 824 (73%) SGs and 191 (17%) RYGBs were performed in patients with T2DM. Diabetes duration with a cutoff value of 5 years and BMI level with 35.5 kg/m² were identified as the influential factors. For patients with diabetes duration > 5 years, RYGB showed a significant higher complete diabetes remission rate than SG at 1 year: 0.52 (95% confidence interval (CI): 0.46-0.58) versus 0.36 (95% CI: 0.30-0.42). For patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m², there was no significant difference between 2 procedures: 0.57 (95% CI: 0.43-0.71) for SG versus 0.66 (95% CI: 0.62-0.70) for RYGB. The cost-effectiveness ratios of SG and RYGB were 244.58 and 276.97 dollars per QALY, respectively.

CONCLUSIONS

For patients with diabetes duration > 5 years, RYGB was the optimal choice with regard to achieving complete diabetes remission at 1 year after surgery. However, for patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m², SG appeared to provide a cost-effective choice.

Improving Hemostasis in Sleeve Gastrectomy With Alternative Stapler

Background:

Staple line bleeding can be a major intra-operative complication during laparoscopic sleeve gastrectomy, requiring reinforcing interventions that may diminish the integrity of the staple line and put patients at risk for postoperative hemorrhage or leak. To improve outcomes associated with surgery, surgeons may benefit from an alternative stapler that produces a drier staple line and requires less staple line manipulation.

Methods:

Sixty consecutive laparoscopic sleeve gastrectomy procedures were performed by three surgeons; 30 sleeves using the AEON™ Endostapler on THICK MODE and 30 using the Echelon Flex™ Powered Stapler with pulse technique. Stapler performance was measured by incidence and degree of staple line bleeding. Images of the first firing and fundus were taken with the laparoscope 10 seconds after the final firing. Images were evaluated by a third-party blinded evaluator and given a “bleeding score,” a qualitative measure of intra-operative staple-line bleeding (1 = no bleeding to 5 = profuse bleeding).

Results:

The AEON™ Endostapler demonstrated a lower mean (± standard error) “bleeding score” versus the Echelon Flex™ (2.1 ± 0.1 vs. 2.6 ± 0.1; p = 0.01). The AEON™ Endostapler had 15 cases (50%) with no bleeding at the fundus; the Echelon Flex™ had 7 cases (23%) with no bleeding at the fundus. The AEON™ Endostapler had 0 cases (0%) with profuse bleeding; the Echelon Flex™ had 2 cases (7%) with profuse bleeding.

Conclusion:

The AEON™ Endostapler is a significantly drier alternative to the Echelon Flex™ Powered Stapler, producing a much drier staple line and decreasing the need for other bleeding control methods.

Effectiveness of Bariatric Surgery in Increasing Kidney Transplant Eligibility in Patients with Kidney Failure Requiring Dialysis

PURPOSE

Severe obesity can increase risk of complications after kidney transplantation. There is a paucity of literature on bariatric surgery outcomes in renal transplant candidates. The objective of this study was to analyze outcomes of bariatric surgery as a weight reduction strategy for patients with kidney failure to enhance eligibility for kidney transplantation.

MATERIALS AND METHODS

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database at a single institution for patients with chronic kidney disease receiving hemodialysis therapy (CKD G5D) undergoing bariatric surgery between 2011 and 2018.

RESULTS

Of 2363 patients who underwent bariatric surgery, 38 (1.6%) had CKD G5D; median age (range) was 49 years (33; 69), 52.6% were female, and mean BMI was 44.2 kg/m². Twenty-four patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), and 14 patients underwent laparoscopic sleeve gastrectomy. Seventeen patients (46%, n=37) had a BMI≤35 at 6 months, while 25 patients (75.8%, n=33) achieved a BMI≤35 at 12 months. Of these, 18 patients (47%) were listed for kidney transplant, and 8 patients (21%) received kidney transplant. There was no statistically significant difference between sleeve and LRYGB procedures in patients who reached BMI of 35 at 12 months (P=0.58). Median length of stay was 2.3 days. Thirty-day readmission rate was 2 patients (5.3%), and 2 patients (5.3%) required reoperation (one for bleeding, one for acute recurrent hiatal hernia). No mortality occurred.

CONCLUSION

Laparoscopic bariatric surgery offers effective weight loss for CKD G5D patients to achieve transplant eligibility with acceptable outcomes.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

To oversew or not to oversew in robotic sleeve gastrectomy: a case against oversewing the staple line

BACKGROUND

The benefits of oversewing the staple lines during laparoscopic sleeve gastrectomy have been controversial. No study examined the benefit of oversewing the staple lines in robotic sleeve gastrectomy (RSG). This retrospective study aims to examine the difference in immediate postoperative complications, readmissions, reoperations, and emergency room visits between RSG patients with and without oversewn staple lines at a single, large-volume, bariatric center.

METHODS

A retrospective chart review was conducted on 623 patients who underwent RSG between November 1, 2017, and November 1, 2019. Of these, 316 had their staple line oversewn between November 1, 2017, and November 12, 2018, and 307 did not have their staple line oversewn between November 13, 2018, and November 1, 2019.

RESULTS

A total of 623 patients underwent RSG, of which 50.7% (n = 316) had their staple line oversewn. The mean length of hospital stay was similar between the two groups. However, the mean operative time was significantly longer in the "oversew" group than "no oversew" group by 7.4 minutes (p < 0.001). Readmission, reoperation, and intervention rates during the 30-day postoperative period were similar between the two groups. However, the percentage of patients requiring outpatient emergency room visits during the 30 days after RSG was significantly higher in the "oversew" group than that of the "no oversew" group.

CONCLUSIONS

No significant difference in major complications was found between RSG patients with and without oversewn staple lines. Oversewing of the staple line may be associated with increased emergency room visits.

Endoscopic Management of Postoperative Complications

Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.

Sleeve gastrectomy in class 1 obesity: Assessment of operative outcomes

BACKGROUND

The risk/benefit ratio of sleeve gastrectomy (SG), especially in patients without type 2 diabetes (T2D), is unknown for patients with class 1 obesity.

OBJECTIVES

Assessment of operative outcomes of SG in class 1 obesity.

SETTING

Private practice.

METHODS

Candidates for a primary SG with body mass index 30-35 kg/m² after 5 years of unsuccessful dieting were included after informed consent was obtained. Participants who did not complete 3-month follow-up and those who underwent modified SGs were excluded. Data and complications were recorded prospectively. Patients were followed up at 3, 6, and 12 months and yearly thereafter. Definition of presence and remission of T2D and insulin resistance were set according to guidelines. Effects on weight loss parameters were evaluated with Wilcoxon signed-rank test.

RESULTS

Between 2012 and 2020, 143 consecutive SGs were performed in patients with class 1 obesity without conversion, leak, mortality, or a venous event. Two were lost to follow-up. In 141 participants, 2 bleedings and 1 colon perforation occurred (2.1% rate for acute life-threatening events). During a mean follow-up of 25.9 months; 1 case of functional stenosis and 4 cases of de novo symptomatic cholelithiasis clinically became evident in different patients, all requiring reoperation. Therefore a 5.6% rate of major complications were identified at 2 years. The benefit on weight loss was immediate and permanent (P < .001). T2D and insulin resistance were in remission in 100% and 98.1% of participants at 1 year, respectively.

CONCLUSION

The 5.6% major complication rate reflects a minimum because more de novo symptomatic gallstones and stenosis are yet to occur or overlooked. Additionally, this excludes patients with de novo reflux and malnutrition, dissatisfaction issues, or recidivism. Caution is required to freely operate on patients with class 1 obesity with no co-morbidity. Evidence-based outcome data are lacking to balance the reported risks.

Safety of Single Stage Revision Laparoscopic Sleeve Gastrectomy Compared to Laparoscopic Roux-Y Gastric Bypass after Failed Gastric Banding

Background

Reoperation, after failed gastric banding, is a controversial topic. A common approach is band removal with conversion to laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in a single-step procedure.

Objective

This study aimed to assess the safety of revisional surgery to LSG compared to LRYGB after failed laparoscopic adjustable gastric banding (LAGB) based on MBSAQIP Participant User File from 2015 to 2018.

Methods

Patients who underwent a one-stage conversion of LAGB to LSG (Conv-LSG) or LRYGB (Conv-LRYGB) were identified in the MBSAQIP PUF from 2015 to 2017. Conv-LRYGB cases were matched (1:1) with Conv-LSG patients using propensity scoring to control for potential confounding. The primary outcome was all-cause mortality.

Results

A total of 9974 patients (4987 matched pairs) were included in the study. Conv-LRYGB, as compared with conv-SG, was associated with a similar risk of mortality (0.02% vs. 0.06%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.03 to 3.20, p = 0.32). Conversion to LRYGB increased the risk for readmission (6.16% vs. 3.77%; RR, 1.63; 95%CI, 1.37 to 1.94, p < 0.01); reoperation (2.15% vs. 1.36%; RR, 1.57; 95%CI, 1.17 to 2.12, p = <0.01); leak (1.76% vs. 1.02%; RR, 1.57; 95%CI, 1.72 to 2.42, p < 0.01); and bleeding (1.66% vs. 1.00%; RR, 1.66; 95%CI, 1.7 to 2.34, p < 0.01).

Conclusions

The study shows that single-stage LRYGB and LSG as revisional surgery after gastric banding, are safe in the 30-day observation with an acceptable complication rate and low mortality. However, conversion to LRYGB increased the risk of perioperative complications.

(S029) Managing therapeutic anticoagulation in bariatric surgery patients

INTRODUCTION

Patients that undergo bariatric surgery are at risk of bleeding. Some obesity-related comorbidities including venous thromboembolism and heart disease can often require therapeutic anticoagulation. Previous small institutional studies have demonstrated that bariatric surgery can be performed in this patient population. This study attempts to identify best practices in stopping and restarting therapeutic anticoagulation in patients undergoing bariatric surgery.

METHODS

A retrospective analysis was completed of our institution's database using anticoagulant medications to identify patients on therapeutic anticoagulation. Patients not on therapeutic anticoagulation were excluded, as well as patients that were started on therapeutic anticoagulation only in the post-operative period or those whose anticoagulation was stopped and not restarted. Indications for anticoagulation were recorded, as well as patient demographics and comorbid conditions. The patient chart was examined for when anticoagulation was stopped before surgery, when it was restarted after surgery, and whether or not the patient was therapeutically bridged. Baseline and post-operative hemoglobin values were recorded, as well as bleeding events, transfusions, reoperation, length of stay, and readmissions. Binary variables were compared across groups using Chi-square and Fisher's exact tests, and continuous variables were analyzed using T test.

RESULTS

There were 2933 bariatric operations performed between January 1, 2012 and August 31, 2019. Of these patients, 64 were on therapeutic anticoagulation before and after the operation for one or more indications, including history of VTE (39), atrial fibrillation (27), clotting disorder (6), ventricular assist device (5), previous PCI (4), or mechanical valve (2). There were 4 (6.2%) patients that experienced bleeding events. All four patients were on Coumadin pre-operatively. Three patients experienced extraluminal bleeding, and one patient had intraluminal bleeding, and all events occurred within 72 h of the operation. All four patients had their anticoagulation restarted prior to the bleeding event becoming evident, with anticoagulation in these patients restarted an average of 1.25 days after surgery. There were no conditions that predisposed a patient to bleeding. There was no significant difference in amount of time anticoagulation was stopped before surgery in bleeding versus non-bleeding patients, and there appeared to be no increased risk of bleeding in patients that were on therapeutic bridging therapy. There were no thrombotic complications from the interruption in anticoagulation therapy.

CONCLUSIONS

Bariatric surgery can be safely performed in patients on therapeutic anticoagulation, though this population is at greater risk for bleeding complications in the perioperative period. Meticulous hemostasis in the operating room is the most important aspect of preventing bleeding complications.

Trends and Outcomes of Laparoscopic Sleeve Gastrectomy Between 2015 and 2018 in the USA and Canada

BACKGROUND

Given there are approximately 100,000 primary laparoscopic sleeve gastrectomy (LSG) procedures performed a year in North America, there is a need to evaluate recent trends in LSG. The objective of this study was to analyze the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to identify trends in technical factors and patient outcomes over time.

METHODS

The MBSAQIP prospectively collects data from 854 centers in the USA and Canada. Patients undergoing primary LSG were included. Statistical analysis was performed to characterize trends in patient factors, technical factors, and 30-day postoperative outcomes.

RESULTS

A total of 434,030 patients underwent primary LSG. The mean age was 44.2 (SD 12.0) years and mean body mass index was 45.1 (SD 7.8) kg/m². Baseline demographics did not vary appreciably by year. Operative time decreased from 2015 to 2018 (75.4 to 70.6 min, p < 0.001). Bougie size and stapling distance from the pylorus did not change by year. However, staple line reinforcement (66.8 to 63.2%, p < 0.001) and oversewing of the staple line (23.1 to 20.1%, p < 0.001) were less commonly performed. Postoperatively, from 2015 to 2018, there was a 45.8% relative reduction in leaks (0.48 to 0.26%, p < 0.001). There were also reductions in 30-day major complications (2.87 to 2.28%, p < 0.001), length of stay (1.72 to 1.44 days, p < 0.001), and readmissions (3.39 to 2.77%, p < 0.001).

CONCLUSIONS

From 2015 to 2018, there was a decrease in staple line reinforcement and oversewing. These changes correlated with reductions in operative time, length of stay, readmission, and major complications.