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

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

Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy

BACKGROUND

Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding.

METHODS

Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance.

RESULTS

One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5 days, p < 0.001).

CONCLUSIONS

Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.

Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015-2016 PUF

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity.

OBJECTIVE

To investigate the relationship between various SLR techniques and bougie size with 30-day outcomes.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery hospitals.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 Participant Use File data, primary LSG cases were divided into study groups based on surgical techniques. All variables were reported in the Participant Use File except leak rate and overall morbidity, which had to be derived. Multiple bivariate analyses were used to analyze the 30-day outcomes.

RESULTS

A total of 198,339 primary LSG operations were included and grouped into No SLR (23.0%), SLR (54.2%), oversewn staple line (9.5%), and a combination of SLR + oversewn staple line (13.3%). There were no statistical differences between study groups in mortality, overall morbidity, or leak rate. Bleeding and reoperation rates were statistically higher in the No SLR group. Bougie size was not associated with change in leak rates.

CONCLUSION

Primary LSG is a safe procedure with low morbidity and mortality rates. SLR is associated with decreased rates of bleeding and reoperations but does not affect leak rates. The selection of SLR technique should be left to the surgeon's discretion with an understanding of the associated risks, benefits, and costs.

Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients

BACKGROUND

Gastric leaks and bleeding are the most important complications after laparoscopic sleeve gastrectomy (LSG). The use of absorbable membranes as staple line reinforcement may decrease this risk. On the other hand, these materials bring additional costs and their economic impact is not well known. The purpose of this study was to assess the clinical and economic performance of one of the commercially available buttressing absorbable materials when treating a high-risk population.

METHODS

A retrospective, observational, and comparative study was conducted at Montpellier University Hospital, France, between July 2013 and September 2014. Patients undergoing LSG, who were at a high risk for leaks and bleeding, were included and treated according to two groups: no buttressing (July 2013 to January 2014) and buttressing (February 2014 to September 2014). Clinical and economic outcomes were measured throughout the first 6 months.

RESULTS

Two hundred two patients were included in the study: 116 during the no stapling reinforcement period and 86 during the buttressing period. Baseline characteristics were similar. There was no significant difference between the two groups regarding gastric leaks. However, buttressing reduced hemorrhagic complications (0 vs 8.6 %, p = 0.005) and decreased average total hospital costs for the first hospitalization (5768 vs 6025 €, p < 0.001), as well as 6-month total inpatient cost (5944 vs. 6246 €, p < 0.001).

CONCLUSIONS

Staple line reinforcement with absorbable material reduces bleeding in high-risk population. Therefore, this type of material can also result in cost-savings.

Staple Line Reinforcement Methods in Laparoscopic Sleeve Gastrectomy: Comparison of Burst Pressures and Leaks

Background and Objectives:

Laparoscopic sleeve gastrectomy is a technically simple and popular bariatric operation with acceptable results. However, leaks can occur in long staple lines, for which various reinforcement methods are used. We compared nonreinforced stapling in laparoscopic sleeve gastrectomy with 3 staple line reinforcement methods: suturing, absorbable buttressing material, and fibrin glue.

Methods:

From March 1 until September 30, 2014, 118 patients with body mass index >40 kg/m² underwent sleeve gastrectomy and were enrolled in 4 groups, depending on the type of reinforcement used. The resected stomach specimens were treated with the same methods of reinforcement as used in the surgeries in the corresponding patients and then insufflated until a burst occurred. The burst pressures of the resected stomach specimens and adverse postoperative events were recorded.

Results:

Five postoperative leaks occurred in the reinforcement groups (fibrin glue, 2; absorbable buttresses, 2; sutures, 1); no leaks were evident in the no-reinforcement group. Suturing afforded the highest burst pressure and took the longest to perform of the methods. There was no correlation between the leaks and burst pressures. All of the leaks occurred in the proximal fundus in the resected stomach specimens and in the affected patients.

Discussion:

Although most surgeons use additional reinforcement on long staple lines in sleeve gastrectomy, there is no consensus about its necessity. We did not show any benefit of such reinforcement methods over proper stapling technique alone.

Conclusion:

Laparoscopic sleeve gastrectomy without staple line reinforcement is safe and avoids additional costs for reinforcement materials.