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Xie Y, Wen J, Zhu H, Liu Y. The Effects of Reinforcement Techniques in Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Protocol for a Web-Based Survey, Systematic Review, and Meta-Analysis. JMIR Res Protoc 2023; 12:e50677. [PMID: 38133924 PMCID: PMC10770791 DOI: 10.2196/50677] [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: 07/09/2023] [Revised: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The effects of reinforcement are still controversial in bariatric surgery, and variations may exist in using this technique. OBJECTIVE This protocol describes a study that aims to survey the views of bariatric surgeons on reinforcement techniques and evaluate the effects of applying reinforcement techniques in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS This study is composed of 2 parts. Part 1 will investigate the differences of using reinforcement techniques among surgeons worldwide who perform SG or RYGB through a survey. The survey will be conducted by email and social media. Part 2 will evaluate the safety and effectiveness of using omentopexy or staple line reinforcement in SG and RYGB by systematic review and meta-analysis. In this part, literature searches will be performed in English databases, including CENTRAL, EMBASE CINAHL, Web of Science, and PubMed, and Chinese databases, including Wanfang, China National Knowledge Infrastructure, Database of Chinese Technical Periodicals, and Chinese Biological Medicine, from their establishment to November 2023. Randomized controlled trials and case-control studies will be included. The primary outcomes are rates of postoperative bleeding and gastric leakage. The secondary outcomes include anastomotic stenosis, surgical site infection, reoperation, estimated intraoperative blood loss, operative time (minutes), length of hospital stay (days), overall complications, and 30-day mortality. The meta-analysis will be conducted using RevMan 5.4 under the random-effects model, as well as through extensive subgroup and sensitivity analyses. P values <0.05 will be considered statistically significant. This study was registered with PROSPERO (Prospective Register of Systematic Reviews) in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols). RESULTS The results of this study will be published in a peer-reviewed journal. The web-based survey and initial title or abstract review of papers identified by the search strategy will be completed in November 2023. The second round of title or abstract review and downloading of the papers for full-text inclusion will be completed in January 2024. We aim to complete data extraction and meta-analysis by February 2024 and expect to publish the findings by the end of March 2024. CONCLUSIONS This study aims to investigate the impact of reinforcement techniques on reducing the incidence of postoperative complications in SG and RYGB procedures and provide assistance for standardizing the procedures of SG and RYGB operations for bariatric surgeons. TRIAL REGISTRATION PROSPERO CRD42022376438; https://tinyurl.com/2d53uf8n. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/50677.
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Affiliation(s)
- Yunhui Xie
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Jun Wen
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Hongmei Zhu
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Yanjun Liu
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
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El Masry MAMA, Attia MS. A comparative study between staple line reinforcement during laparoscopic sleeve gastrectomy and no reinforcement: an Egyptian experience. Surg Endosc 2023; 37:9318-9325. [PMID: 37891370 PMCID: PMC10709468 DOI: 10.1007/s00464-023-10497-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/23/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years. PATIENTS AND METHODS This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR. RESULTS The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289). CONCLUSION This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.
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Vu AH, Chiang J, Qian Y, Tursunova N, Nha J, Ferzli G. Do all roads lead to Rome? A retrospective analysis on surgical technique in sleeve gastrectomy. Surg Endosc 2023; 37:8064-8071. [PMID: 37488445 DOI: 10.1007/s00464-023-10298-1] [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: 04/04/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND New York University Langone Health has three accredited bariatric centers, with 10 different bariatric surgeons. This retrospective analysis compares surgeon techniques in laparoscopic or robotic sleeve gastrectomy (SG) to identify associations with perioperative morbidity and mortality. METHODS All adults who underwent SG between 2017 and 2021 at NYU Langone Health were evaluated via EMR and MBSAQIP 30-day data. We also surveyed all 10 bariatric surgeons and compared their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS 86 (2.77%) out of 3,104 patients who underwent SG encountered an adverse event. Lower adverse outcomes were observed with a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, and no routine UGI series. Lower bleeding rates were observed in a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, no routine UGI series, and not proceeding with SG if hiatal hernia is present. Lower SSI rates were observed with ViSiGi™ bougie, no hemostatic agents, and routine EGD. Lower readmission rates were observed with 40-Fr bougie, buttressing, not oversewing, and stapling 3-cm from pylorus. Hemostatic agents had higher reoperation rates. It was not feasible to test for mortality given the low incidence. CONCLUSION Certain surgical techniques in SG among our bariatric surgeons had a significant effect on the rates of adverse outcomes, bleeding, readmission, reoperation, and SSI. Our findings warrant further investigation into these techniques via multivariate regression or prospective design. LIMITATIONS This study was limited by its retrospective and univariate design. We did not account for interaction. The sample size was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.
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Affiliation(s)
- Alexander Hien Vu
- Department of General Surgery, New York University Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA.
| | - Jessica Chiang
- Department of General Surgery, New York University Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA
| | - Yunzhi Qian
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Nilufar Tursunova
- Department of General Surgery, New York University Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA
| | - Jaein Nha
- Department of General Surgery, New York University Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA
| | - George Ferzli
- Department of General Surgery, New York University Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA.
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Meissner M, Hafermann J, Silas U, Saunders R. Evaluating the Environmental Impact of Single-Use and Multi-Use Surgical Staplers with Staple Line Buttressing in Laparoscopic Bariatric Surgery. Risk Manag Healthc Policy 2023; 16:1423-1433. [PMID: 37560134 PMCID: PMC10408667 DOI: 10.2147/rmhp.s415989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE Operation rooms have a large environmental impact. Single-use staplers (SUS) are widely used surgical instruments that contribute to resource consumption and waste generation, whereas multi-use staplers (MUS) can greatly reduce the environmental impact of surgery. The staple lines are often reinforced with buttressing material to prevent leaks and bleeding. We explore current clinical practice and environmental concerns regarding stapling and buttressing, as well as the environmental impact of staple line buttressing in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, we extend this analysis by taking packaging material and the lithium in power supplies into consideration. MATERIALS AND METHODS A survey of bariatric surgeons was conducted to assess stapler and buttressing use in clinical practice. We deconstructed and analyzed the product and packaging composition of a commonly used SUS with separate staple line reinforcement (Echelon Flex™ with Echelon Endopath™, Ethicon) and MUS (Signia™ with Tri-Staple™ reinforced reloads, Medtronic), where the buttressing material was delivered separately or already incorporated in the reload cartridge, respectively. Both systems were compared regarding total waste generation, resource use (determined as total material requirement), and greenhouse gas emission caused by their lithium content. RESULTS 60 mm cartridges were most frequently used in bariatric surgery, and 67% of surveyed surgeons applied staple line reinforcement. MUS with pre-attached buttressing resulted in a reduction of waste, material consumption, and greenhouse gas emissions compared to SUS with separate buttressing: they reduced product waste by 40% (SG and RYBG), packaging waste by 60% (SG) and 57% (RYGB), resource consumption by more than 90%, and greenhouse gas emissions related to the lithium in the batteries by 99.7%. Preloaded buttressing produced less waste than separate buttressing per stapler firing. CONCLUSION The environmental impact of surgery can be greatly reduced by using MUS with pre-attached buttressing rather than SUS with separate buttressing.
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Affiliation(s)
| | | | - Ubong Silas
- Coreva Scientific GmbH & Co. KG, Koenigswinter, Germany
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Prediction Factors of Early Postoperative Bleeding after Bariatric Surgery. Obes Surg 2022; 32:1-8. [PMID: 35474043 DOI: 10.1007/s11695-022-06059-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 12/15/2022]
Abstract
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.
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Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg 2022; 32:1466-1478. [PMID: 35169954 PMCID: PMC8986671 DOI: 10.1007/s11695-022-05950-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Purpose Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR. Materials and Methods Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures. Results Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality. Conclusions SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-022-05950-z.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy.
| | | | - Marco Antonio Zappa
- UOC Chirurgia Generale Ospedale Fatebenefratelli, Asst Fatebenefratelli-Sacco Milano, Milan, Italy
| | - Caterina Lastraioli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Francesca Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Valerio Panizzo
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Marta Cavalli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Giampiero Campanelli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
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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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Trindade EN, Leite C, Trindade MRM. Oversewing the Staple Line. It Is Really Necessary? J INVEST SURG 2020; 35:413. [PMID: 33207967 DOI: 10.1080/08941939.2020.1849466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Eduardo Neubarth Trindade
- Division of Digestive Surgery, Hospital de Clinicas de Porto Alegre and Discipline of Clinical and Operative Techniques, UNISINOS, Porto Alegre, Brazil
| | - Carine Leite
- Division of Gastroenterology, Hospital Moinhos de Vento and FEEVALE, Porto Alegre, Brazil
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Emile SH. Invited Commentary on "Is there Necessity for Oversewing the Staple Line during Laparoscopic Sleeve Gastrectomy? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials". J INVEST SURG 2019; 33:851-852. [PMID: 30848968 DOI: 10.1080/08941939.2019.1574322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sameh Hany Emile
- Mansoura Faculty of Medicine, General Surgery Department, Mansoura University, Egypt
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