Staple Line Reinforcement Research Articles

Cost-effectiveness of Staple Line Reinforcement in Laparoscopic Sleeve Gastrectomy.

To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy. Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is staple-line reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy. Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Quality-adjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed. A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts ( P = 0.8841); 0.45% compared with 0.59% for minor bleed ( P < 0.0001); and 0.24% compared with 0.26% for leak ( P = 0.4812). Median cost for a major bleed was $5552 ($3287, $16,817) and $2406 ($1861, $3484) for a minor bleed. Median leak cost was $9897 ($4589, $21,619) and median cost for patients who did not experience a bleed, leak, or other serious complication was $1908 ($1712, $2739). Mean incremental cost of reinforced stapling compared with standard was $819.60/surgery. Net QALY gain with reinforced stapling compared with standard was 0.00002. The resultant incremental cost-effectiveness ratio was $40,553,000/QALY. One-way and probabilistic sensitivity analyses failed to produce a value below $150,000/QALY. Compared with standard stapling, reinforced stapling reduces minor postoperative bleeding but not major bleeding or leaks and is not cost-effective if routinely used in laparoscopic sleeve gastrectomy.

Comparative study of non reinforced staple line and reinforced staple line during laparoscopic sleeve gastrectomy

Background: Staple line bleeding & leak are the most annoying events of Laparoscopic Sleeve Gastrectomy. Staple line reinforcement (SLR) is considered a weapon to reduce the incidence of such dangerous events. Purpose: Rationale of this study is to compare between non reinforced and reinforced staple line with vicryl sutures during laparoscopic sleeve gastrectomy. Patients and methods: Patients were divided into two groups; group (A); 25 cases; underwent Laparoscopic Sleeve Gastrectomy (LSG) with strength­ening of the stapler line by v-lock suture and group (B); 25 cases; underwent LSG without reinforcement of stapler line. patient follow-up period was 12 months. Results: There were no significant differences between both groups as regard to patient demographic data and hospital stay. Group (A) was performed in longer time; 102 ± 9 vs 74 ± 4 in group (B). frequency of bleeding was more in group (B); 7 patients (28%) than in group (A); one patient (4%). Also frequency of leakage was more group (B); 6 patients (24%) than in group (A); no patients (0%). P-value was for bleeding and leakage; 0.049 & 0.022. Conclusions: Sleeve gastrectomy by laparoscopy is a safe, minimally invasive and easy operative procedure. Adding reinforcement of the whole staple line is easy method to reduce the rate and severity of the postoperative bleeding and leakage to a great extent. Additional cost due to invaginating the whole staple line may be counterbalanced by the reduction in the length of hospital stay.

Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies.

PurposeAmong 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.MethodsAll 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.ResultsBetween 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.ConclusionFTCS 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 InformationThe online version contains supplementary material available at 10.1007/s00423-021-02161-5.

Laparoscopic Sleeve Gastrectomy, with or without Staple Line Reinforcement

Background: Overweight and obesity are defined as abnormal or excessive fat accumulation that presentsa risk to health. A crude population measure of obesity is the body mass index. The surgical treatmentof morbid obesity is termed bariatric surgery, Laparoscopic sleeve gastrectomy first described by Gagner.Specific complications have been reported, including staple-line bleeding and staple-line leaks, Staple linereinforcement is extensively debated and highly recommended by most surgeons in an attempt to reducepostoperative complication.Aim of the Study: To compare the early complication of sleeve gastrectomy with or without staple linereinforcement by over-sewing.Patients and Method: Prospective study from 1st January 2013 to 31st January 2015, four or five ports usedaccording to surgeon preference but all of them used graduated cartridge size, some of them used to reinforce the staple line by Prolin or Vicryl and others did not. The patient was follow up for one month aftersurgery by direct contact with the surgical team.Conclusion: there was no statistically difference in the incidence of leak or bleeding in cases of sleevegastrectomy with or without staple–line reinforcement by over sewing.

Can staple-line reinforcement eliminate the major early postoperative complications after sleeve gastrectomy?

BackgroundStaple line reinforcement (SLR) is widely used to reduce major complications such as bleeding and leak after sleeve gastrectomy (SG). The present study aims to compare the running suture of SLR with a hybrid method by purse string suture of His angle, continuous inverted suture of proximal staple line and oversewing of distal staple line with omental coverage. MethodsThis single center retrospective study included 914 patients underwent SG. Their surgical videos were reviewed. The patients were divided into two groups according to the SLR methods, including hybrid suture and running suture. The postoperative major complications, including bleeding, leak and obstruction, were evaluated. ResultsAmong 914 patients, 384 had hybrid suture while 530 had running suture of SLR. The overall incidence of staple line bleeding and disruption was 39.2% and 4.9% after stomach transection. Hybrid suture exhibited slightly shorter SLR suture time, and required less extra suture for the hemostasis of suture site bleeding after staple line reinforcement compared to running suture. The incidence of postoperative bleeding was significantly lower after hybrid suture than after running suture (0 vs 1.3%, P = 0.02). Two patients in running suture group were complicated with postoperative leak. There was no postoperative obstruction within all patients. 1-year excessive weight loss was similar between two groups. ConclusionDespite surgical complexity, hybrid suture seemed to be able to decrease the incidence of postoperative bleeding compared to running suture. However, its role on leak and obstruction requires further clinical validation.

Evaluation of staple line reinforcement after partial gastrectomy closure in an ex vivo canine model.

To determine the influence of stapling on leakage pressures after canine partial gastrectomy. Ex vivo study. Gastric specimens from 24 adult canine cadavers. Partial gastrectomy constructs were assigned to one of three closure techniques (n = 8 per group): group 1, stapled closure with a 90-mm thoracoabdominal stapling device and a 4.8-mm staple cartridge; group 2, hand-sewn double-layer inverting suture closure with 3-0 glycomer 631; and group 3, staple line reinforcement with an inverting Cushing suture pattern. Leakage and pressure testing were performed. Initial leakage pressure (ILP), maximal leakage pressure (MLP), and leakage location were recorded. Significance was set at P < .05. Placement of a Cushing suture (group 3) increased ILP and MLP by 3.2-fold and 2.8-fold, respectively, compared with stapled closures alone (P < .001). Constructs closed with double-layer suture closure reached ILP and MLP 4.5-fold and threefold greater, respectively, compared with those with stapled closures alone (P < .001). Maximal leakage pressure did not differ between groups 2 and 3 (P = .14). Leakage occurred from the inverting suture line in all constructs of groups 2 and 3 and from staple holes in six of eight group 1 constructs. Double-layer suture closure of canine partial gastrectomies achieved superior biomechanical properties compared with stapled closure techniques. Reinforcing staple closures with an inverting suture line improved resistance to leakage. Reinforcing single-layer closure of partial gastrectomies with an inverting Cushing pattern is recommended to improve resistance to leakage. In vivo investigation is warranted to evaluate influence of closure technique on gastric healing, postoperative stasis, ischemic injury, and postoperative dehiscence.

The impact of the last ten minutes of surgery on hemorrhagic complications after laparoscopic sleeve gastrectomy. Case-control study.

IntroductionHemorrhagic complications after laparoscopic sleeve gastrectomy (LSG) are among the most common adverse events. The last 10 min of LSG are essential in terms of hemostasis.AimTo assess the blood pressure profile in the last 10 min of LSG in patients who experienced hemorrhagic complications after laparoscopic sleeve gastrectomy.Material and methodsWe performed a retrospective case-control study. The medical records of 867 patients who underwent primary LSG were analyzed. Cases were defined as patients who required surgical revision due to hemorrhagic complications within 72 h. Controls were matched (1 : 1) with cases by age, body mass index, gender, staple line reinforcement, comorbidities and surgeon’s experience. Comparison of the last three intraoperative blood pressure measurements at the end of surgery was made.ResultsThe bleeding rate was 3.0%. A total of 24 subjects (12 matched pairs) were included in the study. Cases had statistically significant increased mean arterial blood pressure (mm Hg) 5 min before the end of surgery (87.8 ±11.9 vs. 79.4 ±8.8 mm Hg, p = 0.049) and at the end of surgery (89.2 ±11.7 vs. 77.5 ±11.8 mm Hg, p = 0.011). Higher diastolic blood pressure measurements were observed 5 min before the end (72.1 ±10.7 vs. 62.8 ±8.1 mm Hg, p = 0.023) and at the end of surgery (74.2 ±10.0 vs. 60.8 ±11.2 mm Hg, p = 0.004).ConclusionsCompared with closely matched control subjects, patients with HC after LSG have increased mean arterial pressure in the last 5 min of surgery. This phenomenon has not been reported in the literature before.

Risk of anastomotic bleeding after left colectomy with preservation of inferior mesenteric artery for diverticular disease: preliminary results

Background The inferior mesenteric artery (IMA) preservation in elective laparoscopic left colectomy for diverticular disease may reduce the risk of anastomotic leakage. However, an increased risk of bleeding is assumed. The purpose of this study is to investigate the risk of colorectal anastomosis bleeding, when IMA is resected or preserved during left colectomy. Methods A retrospective review of a prospectively collected database was performed. All patients who underwent elective left colectomy, from December 2018 to September 2020, were included. Patients' data and clinical information were collected and analyzed. Patients were categorized in two group: IMA resected (IMAR) and IMA preserving (IMA-P) left colectomy. Perioperative outcomes between the two groups were compared. Results Sixty-three consecutive patients who underwent left colectomy over a period of three years were enrolled: 42 in IMA-R group and 22 in the IMA-P group. There were no significant differences in demographic and intraoperative characteristics between the two groups, except for patients' age and primary disease. Six patients (9.37%) developed anastomotic bleeding during recovery, more frequently in the IMA-P than IMA-R group, although the difference is not statistically significative (13.6% and 7.3%; p=0.406). All bleedings were self-limited and only one needed red blood cells transfusion. Using the bioabsorbable staple line reinforcement (BSLR) has proved to be advantageous in preventing anastomotic bleeding in the IMA-P group. Conclusions IMA preserving left colectomy seems to be associated with a higher risk of mostly selflimited anastomotic bleeding during recovery. BSLR seems to be effective in this group of patients.

Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy

In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes. To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy. In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016. Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing. The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument). A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47). Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.

Comparison of bursting pressure on sleeve gastrectomy staple lines between stapling, buttressing, and oversewing

Backgrounds. One of the major complications after laparoscopic sleeve gastrectomy (LSG) is represented by leaks along the staple line. Several reinforcement techniques have been proposed, but scarce data about the real strengthening offered are present. Thus, we aimed to evaluate if different reinforcements produced different bursting pressures after LSG, and then to verify if the clinical application of the stronger reinforcement produced a reduction in leakage rate. Methods. We prospectively enrolled all consecutive obese patients that underwent LSG. We tested 3 different types of staple lines, as follows: group 1, no reinforcement; group 2, bioabsorbable buttress reinforcement; group 3, invaginating overrunning barbed suture. A burst pressure test was applied to the gastric specimen by means of high-resolution manometric catheter. After burst pressure tests, a subsequent consecutive series of patients were treated with the most effective reinforcement, and rate of leaks was recorded. Results. We enrolled in total 110 obese patients; 20 patients for each group of staple line reinforcement and then other 50 consecutive patients underwent LSG with the higher burst pressure staple line reinforcement. Median burst pressures were similar in group 1 and group 2; group 3 showed a statistically significant pressure increase (P < .0001) than group 1 and group 2, with a 5.2-fold value. Other consecutive 50 obese patients underwent LSG with overrunning reinforcement. In none of them a leak was detected. Conclusions. Reinforcement of the SG staple line, with overrunning suture, seems to drastically increase bursting pressures in an ex vivo model and it is promising when reproduced in vivo.

Role of reinforcement of staple line in laparoscopic sleeve gastrectomy for patients with morbid obesity

Background Postoperative staple line bleeding and leakage after laparoscopic sleeve gastrectomy (LSG) still pose potential challenging complications. Some studies have indicated staple line reinforcement (SLR) to decrease the rate of bleeding and leakage, but its efficacy is still being debated. The aim in this study was to evaluate the incidence of staple line bleeding and leakage during LSG after SLR using absorbable suture material. Patients and methods This was a retrospective study that included 180 consecutive patients who underwent LSG between January 2017 and October 2019 and were divided into two groups: 50 patients in group A (without SLR) and 130 patients in group B (with SLR). The study was conducted in Helwan University hospital and Dar Elshefa and El Merghany private hospitals. Results Postoperative staple line bleeding was 4% in group A compared with 1.5% in group B (P=0.315). Bleeding control by reoperation was 4 and 0% in groups A and B, respectively (P=0.021). Just one patient had leakage in group A (2%) and was managed with endoscopic clipping and stenting (P=0.105). Operative time was shorter in group A than in group B, with mean of 70 and 81.41 min, respectively (P Conclusion SLR by oversewing using absorbable suture material during LSG is safe and efficient in reducing the incidence of reoperation to control postoperative staple line bleeding despite the fact that it significantly increased the operative time. Nonetheless, more studies are needed on a larger number of patients with various reinforcement techniques to prove its effectiveness. SLR with absorbable suture material is safe and efficient in LSG and may reduce the need for reoperation despite prolonging the operating time and not being statistically significant in reducing the incidence of complications such as bleeding or leakage.

Imbrication versus no reinforcement during laparoscopic sleeve gastrectomy

Background Laparoscopic sleeve gastrectomy (LSG) is a common procedure in recent years for treatment of morbid obesity. However, leak and bleeding are its main challenging complications. Despite numerous studies regarding such complications, there is still no conclusion on reinforcement of staple line in this procedure. The purpose of our study was to compare staple line imbrication versus no reinforcement. Objectives To determine the effects of reinforcement of staple line by imbrication using continuous seromuscular invagination using absorbable suture on bleeding, leakage, length of hospital stay, readmission, reoperation rates, and stricture rates. Patients and methods In our pilot study, 60 patients experiencing morbid obesity with BMI above 35 kg/m2 were prepared for LSG. The patients were enrolled randomly into two equal groups comparing the effect of staple line reinforcement by imbrication whole staple line by seromuscular invagination using absorbable suture (group A) versus no reinforcement (group B). The study was conducted in Menoufia University in the period between October 2017 and June 2019. Results Hemorrhage and leak did not occur in group A but occurred in two (6.7%) patients and one (3.3%) patient, respectively, in group B, but stricture occurred in two (6.7%) patients in group A and no patients in group B. Conclusion This pilot study has shown that reinforcement by staple line imbrication as a step in LSG is safe, technically easy, of low cost, and can reduce the incidence of postoperative complications, as bleeding and leakage, although it significantly prolongs the operative time and may lead to increase in the rate of stricture.

Identifying Opportunities for Cost Containment in Surgery: Case Study of Staple-Line Reinforcement Using Cost-Effectiveness Analysis

Johnson, Emily H. BS; Highet, Alexandra BA; Bonham, Aaron J. MS; Zhou, Shuhao MPH; Thalji, Ameen MHSA; Ghaferi, Amir A. MD, FACS Author Information

Efficacy of Staple Line Reinforcement With Omentopexy During Laparoscopic Sleeve Gastrectomy on Postoperative Complications: Experience of a Single Center.

The aim of this study was to evaluate the protective effects of staple line reinforcement with omentopexy during laparoscopic sleeve gastrectomy on postoperative complications. A total of 3942 laparoscopic sleeve gastrectomy cases were included in the study. All the patients were divided into 3 groups: No reinforcement (NoSLR), staple line reinforcement with fibrin glue (SLR-FG), and staple line reinforcement with omentopexy (SLR-O). Demographic data and perioperative characteristics of the groups were analyzed retrospectively. Among these, age, sex, preoperative comorbidities, American Society of Anesthesiologists scores, body mass index, duration of operation, reoperation, complications, and Clavien-Dindo classification scores were recorded. Age, sex, body mass index, comorbid diseases, American Society of Anesthesiologists, and Clavien-Dindo Classification scores were similar in all the groups. The overall complication rate was 3.0%. The overall minor and major complication rates were 1.7% and 1.3%, respectively. The mortality rate was 0.1% (4 patients). The most common postoperative complications were bleeding (0.9%) and leakage (0.5%). The incidence of leakage, bleeding, and twisted gastric sleeve rates were similar when compared between SLR-FG and NoSLR. In the SLR-O patients, the incidence of leakage, hemorrhage, and twist were significantly lower and the operation time was significantly longer when compared with the other groups. The SLR-O technique, especially when performed by experienced surgeons, is a promising method for the prevention of postoperative leakage, bleeding, and twist complications with an acceptable increase in the duration of operation. Considering the limited effects of the SLR-FG technique, it was predicted that it would lose its popularity over time.

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

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. 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. 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 70.6min, 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 1.44days, p < 0.001), and readmissions (3.39 to 2.77%, p < 0.001). 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.

Variations in bariatric surgical practice patterns between general and bariatric surgeons: a matched analysis of the 2017 MBSAQIP database.

While general surgeons (GSs) perform metabolic and bariatric surgery (MABS), these procedures are increasingly performed by metabolic and bariatric surgeons (MBSs). Because MABS is an evolving practice with changing surgical platforms and approaches, it is important to evaluate outcomes between different specialists performing these procedures. To compare perioperative practice pattern variations and outcomes of MABS performed by GSs versus MBSs. University Hospital, United States. Using the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases and stratified them by specialization (GSs versus MBSs). Patient characteristics, practice patterns and outcomes, complications, and 30-day outcomes were compared between cohorts. Matched procedure-specific analyses were performed. Of 172,430 MABS procedures, 4394 (2.5%) were performed by GSs and 168,036 (97.4%) by MBSs. At baseline, patients of GSs had fewer co-morbidities. GSs more commonly used the robotic platform for SG cases and performed interventions such as staple line reinforcement and staple line check with provocative testing. MBSs more commonly performed robotic (versus laparoscopic) RYGB. Overall complications were low in both study cohorts. After propensity matching, transfusion and venous thromboembolism were higher in SG performed by GSs, while surgical site infection was higher in SG and RYGB performed by MBSs. These findings were not reproduced after case-control matching. In matched analyses, there were no mortality or morbidity differences between study cohorts. MABS is performed safely by both GSs and MBSs, with no difference in morbidity andmortality.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass—an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures

There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB. A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors. A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements. This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.

Prospective interventional study of staple line reinforcement and buttressing in laparoscopic sleeve gastrectomy

Background: Laparoscopic sleeve gastrectomy has gained increasing acceptance among bariatric surgeons and patients. The three main options for staple line reinforcement are over-sewing and buttressing with synthetic polymers or biologic tissue. The purpose of this study was to prospectively analyse the relative efficacy of gastric staple line reinforcement (SLR) by using over sewing as the method of reinforcement and comparing it with non-reinforcement laparoscopic sleeve gastrectomy (LSG) in 60 patients who were admitted in IGGMC Nagpur from May 2017 to November 2019.Methods: Obese patients with age 18-65 years, BMI 40 and above with-out co-morbidities and 35 and above with co-morbidities, and BMI below 60, with no malignancy, no hiatus hernia, no previous bariatric procedure were included. All patients underwent LSG after thorough evaluation. 30 patients had reinforced staple line, while 30 had simple staple line.Results: Total 60 patients were studied, 30 in each group. Intraoperative leak was seen in 1 patient each in both study groups. No bleeding was seen in reinforced LSG, while 3 patients had intraop bleeding in simple staple line group. 1 patient each of non-reinforced group had postop leak, postop bleeding and post op morbidity and mortality in 1 patient, while no postop leak or bleeding, morbidity or morality was seen in reinforced group.Conclusions:Reinforcement of staple line by over sewing in LSG resulted in significantly fewer surgical complications, lesser morbidity and no mortality compared to simple stapling of the gastric tube.

Why We Think Laparoscopic Sleeve Gastrectomy Is a Good Operation: Step-by-Step Technique.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world, with 75% of the primary procedures performed in the United States. It is a safe and effective primary bariatric procedure with good weight loss. When comparing with other procedures, LSG is limited to the stomach, avoiding the presence of internal hernias, preserving the pyloric anatomy, with normal gastric emptying, and conveying less severe rebound hypoglycemia. Materials and Methods: We describe the technique, step-by-step, we use to perform a sleeve gastrectomy (SG) and analyze why we think it is a good surgery. Results: The highlights of a safer SG systematization are based on minimum 36F bougie calibration, starting 4-5 cm from the pylorus, keeping ∼1 cm distance from esophagus. We routinely use staple line reinforcement by continuous suture. Comparing with Roux-en-Y gastric bypass, less bowel obstruction, less dumping syndromes, less hypoglycemia, and also less ulcers are described. Conclusion: LSG is a safe and effective primary bariatric procedure with durable weight loss. And when comparing with others with intestinal anastomosis, we found fewer complications such as less internal hernias, access to the bile duct after surgery, and has the great advantage that it can be revised when it fails.

Remodifying Omentopexy Technique Used with Laparoscopic Sleeve Gastrectomy: Does It Change any Outcomes?

Gastric obstructions, leaks and staple line bleeding are reported after laparoscopic sleeve gastrectomy (LSG). There is no ideal method or technique to avoid these mishaps. We added modifiedomentopexy (OP) to LSG to determine if there is any effect on gastric leaks and some other complications. This single institution case control study included two groups of morbidly obese patients undergoing LSG. They were grouped as omentopexy (OP) or no omentopexy (NP). Patient characteristics such as age, sex, ASA (American Society of Anesthesiologists) risk, body mass index (BMI), nutritional status and comorbidities were comparable. Postoperative follow-up was scheduled at 1week, 1month, 3months, 6months and 12months. All received standard postoperative clinical, nutritional evaluation and PPI therapy for at least 3months. Total 737 patients underwent LSG from January 2012 to December 2017. Out of these, 370 that had OP and 367 that had NP were analyzed. NP group was subdivided into Lemberted Staple line (LS) and bioabsorbable staple line reinforcement (BSLR) groups. Gastric leaks and perforations were clubbed together as gastric disruptions (GD). Patients with at least 15months of postoperative follow-up were included. Those who failed to follow up were excluded. GD was reported in 7 out of 367 NP patients (1.9%), while no GD was seen in 370 OP patients (P = 0.01). Bleeding was seen in 1 OP versus 2 NP patients (P = 0.6). Venous thromboembolism was reported in 2 OP versus 1 NP patients (P = 1). Wound infection was seen in 1 OP versus 2 NP patients (P = 0.6). Readmissions were noted in 2 OP versus 6 NP patients (P = 0.1). Pneumonia was seen in 2 OP and 2 NP patients (P = 1). Postoperative dehydration was seen in zero OP versus 1 NP patients (P = 0.4). Gastric obstruction was not seen in any of the patients. Postoperative gastric reflux was present in 49/370(13.2%) OP versus 57/367(15.4%) NP patients (P = 0.4). Within NP group, LS (Lemberting of Staple line) patients (286/367) had 4 GD (1.39%) versus no GD in OP (P = 0.03). BSLR (Bioabsorbable Staple line re-enforcement) patients (81/367) had 3 GD (3.7%) versus no GD in OP (P = 0.005). None of the groups had any mortality. GD (gastric disruptions) were statistically significant, but the following bleeding, venous thromboembolism and gastroesophageal reflux did not reach statistical significance, which indicates that OP, if performed correctly with LSG, has favorable effects on gastric leaks.