Efficacy and effectiveness of suture bolster with Seamguard®

Abstract

The idea of reinforcing staple lines by using a material with the purpose of diminishing suture morbidity is not new. Over the last decades many strategies have been adopted, in both gastrointestinal and thoracic surgery. The first bolsters used for staple lines were nonabsorbable (e.g., expanded polytetrafluoroethylene, ePTFE), semi-absorbable (bovine pericardial and collagen strips), and bioabsorbable materials (L-lactic acid-co-epsilon-caprolactone) [1, 2]. The problem has always been to find the optimal material that yields the greatest advantages in terms of reduced incidence of leakage, stricture, and bleeding of the staple line. Gore Seamguard is a bioabsorbable membrane of polyester braided suture, a random-fiber web of a copolymer glycolide (PGA) and trimethylene carbonate (TMC) microporous structure. The advent of Seamguard in reinforcement of linear sutures yielded good results, reducing the rate of clinical leaks and anastomotic bleeding, and offering satisfactory anastomoses [3–5]. The application of Seamguard to circular staplers ensued and yielded the same good results [6]. Further applications in the strategy of reinforcement of linear sutures have been use of Seamguard for lung resections [7], appendectomy [8], bariatric surgery [9], and gastric surgery [10, 11]. In our experience we have observed some advantages after adopting Seamguard biomaterial as staple-line reinforcement when using linear staplers, in particular in laparoscopic surgery of stomach and distal pancreas. On the whole, since June 2000 we have performed 79 laparoscopic gastrectomies for various pathologies: 6 for benign ulcer, 5 for nodular histiocytic (NH) lymphoma, 2 for gastrointestinal stromal tumor (GIST), and 66 for gastric cancer. We registered three duodenal leaks at the beginning of laparoscopic experience (one following gastrectomy for benign ulcer and two for adenocarcinoma) when we used to merely transect the duodenum by a 45-mm linear cutting stapler without enclosing or reinforcing the staple line (20 cases). From 2002 on, after transecting the duodenum laparoscopically with linear stapler, we enclosed the staple line by separated extracorporeal stitches (9 cases), while after 2003 the staple line was routinely protected with Seamguard (50 cases), since which no leaks have been registered [10, 11]. Certainly, a comparison between enclosing suture versus reinforcement of the staple line would have been of great interest, but the leak rate was nil in both groups, hence such a comparison was nonsense. The reason why we prefer BSG bolster now is only because it is less time consuming than tying extracorporeal slipknots on the duodenal stump. On the other hand, reinforcement by BSG bolster is certainly more expensive. Recently, some interesting studies confirmed the effectiveness of Seamguard in reducing the rate of leak after distal pancreatectomy, in both open surgery [12, 13] and laparoscopy [14, 15]. In our experience we registered a statistically relevant difference with Fisher’s exact test between the leak rate (within 30 days) after pancreatic transection by linear staple plus buttress and by BSG reinforcement [15]. This noticeable outcome in our series has confirmed the statistically significant results obtained in open surgery by others [12, 13]. The polyglycolic acid–trimethylene carbonate BSG (Bioabsorbable Seamguard , WL Gore & Associates, Flagstaff, AZ, USA), is a material absorbable within 6 months. In our series one patient experienced a late pancreatic leak 42 days after surgery, probably due to initial absorption of BSG material that disclosed the presence of an underlying leak. R. Pugliese (&) D. Maggioni F. Sansonna G. C. Ferrari S. Di Lernia A. Forgione C. Magistro Divisione di Chirurgia Generale e Videolaparoscopica, Ospedale di Niguarda Ca’ Granda, Piazza Ospedale 3, 20162 Milano, Italy e-mail: chirurgiaurgenza@ospedaleniguarda.it