Staple Line Leak Research Articles

Staple-line leak post primary sleeve gastrectomy. A two patient case series and literature review

There is an increasing trend in the number of bariatric surgeries performed worldwide, partly because bariatric surgery is the most effective treatment for morbid obesity. Sleeve gastrectomy (SG) remains the most common bariatric surgery procedure performed, representing more than 50% of all primary bariatric interventions. Major surgical complications of SG include staple-line bleeding, leaking, and stenosis. A leak along the staple-line most commonly occurs at the gastroesophageal junction (GOJ).From January 2018 to December 2018, our centre performed 226 bariatric procedures, of which, 97.8% were primary bariatric procedures. The mean age and BMI were 38.7±8.3 years and 44 kg/m2, respectively. Out of the 202 primary SG performed, we encountered two cases of a staple-line leak (0.99%). This is the first reported case series of SG leaks from the Southeast Asia region. A summary of their characteristics, clinical presentation, subsequent management, and the outcome is discussed.Based on the latest available evidence from the literature, several methods may decrease staple-line leaks in SG. These include the use of a bougie size greater than 40 Fr, routine use of methylene blue test during surgery, beginning transection at 2–6 cm from the pylorus, mobilising the fundus before transection, and staying away from the GOJ at the last firing. Other methods include the proper alignment of the staple-line, control of staple-line bleeding, and performing staple-line reinforcement. The management of a staple-line leak remains challenging due to limited systematic, evidence-based literature being available. Therefore, a tailored approach is needed to manage this complication.

Role of Intraperitoneal Drainage after Laparoscopic Sleeve Gastrectomy

Background and aims: Laparoscopic sleeve gastrectomy (LSG) is a very popular bariatric procedure. Intraperitoneal bleeding, haematoma and staple line leak are the most common postoperative complications of LSG. Many surgeons routinely leave an intraperitoneal drain (IPD) thinking it will help in managing complications. Our aim was to evaluate the role of IPD in diagnosing and treating post-operative complications after sleeve gastrectomy. Patients and methods: We collected the data of patients who underwent primary LSG at our department between February 2016 and March 2018. 120 patients (group A) had LSG with positioning of IPD and 105 patients (group B) had LSG without IPD. All operations were performed by the same operative team and were completed laparoscopically. Inclusion criteria were a body mass index (BMI) greater than 40 kg/m2 or greater than 35 kg/ m2 accompanied with relevant co-morbidities. Exclusion criteria were the inability to undergo general anesthesia, patients with previous bariatric procedures, patients with previous intragastric balloon, patients on anticoagulation and patients older than 60 years. Results: The two groups were not different in their outcome. In Group A, 3(2.5%) patients had bleeding ( only one was evident in the drain) managed conservatively, one(0.8%) of them later on had surgical bed haematoma treated by U/S guided aspiration and pigtail insertion. Also in group A, one case (0.8%) of leakage managed by endoscopic stent and laparoscopic lavage and draining. In Group B, 4 cases (3.8%) had bleeding managed conservatively, 2 of them (1.9%) had haematoma later on managed by U/S guided aspiration and pigtail insertion. No leakage occurred in group B. Conclusions: Insertion of drains does not help in diagnosing or treating post-LSG complications as bleeding, leakage or haematoma.

ROLE OF MDCT IN ASSESSMENT OF EARLY POST-OPERATIVE COMPLICATIONS IN SLEEVE GASTRECTOMY IN BARIATRIC PATIENTS

Background: laparoscopic sleeve gastrectomy (LSG) is one among different bariatric surgeries, which became an effectivetreatment method for morbid obesity. CT may be performed after laparoscopic sleeve gastrectomy to assess acute complications as staple line leakage, abscesses, hematomas, portal vein thrombosis (PVT), splenic injury or infarction.Aim of the study: was to assess the value of multi- detector CT in the evaluation of the suspected early complications of LSG. Patients and Methods: This study was an observational study, included 25 patients who underwent LSG and CT was done for them to detect any suspected complication even in the presence of negative upper gastrointestinal (UGI) series.Results: MDCT detected complication in 15 patients out of the 25 patients (60%), with no mortality. Leakage occurred in 16%, abscess in 8%, hematoma in 8%, splenic injury, splenic infarction and PVT in 4% each. Conclusions: CT is an important imaging tool to diagnose suspected complications of laparoscopic sleeve gastrectomy procedure and should be used to ensure accurate diagnosis or in the case of mismatch between symptoms and routine upper GIT studies.

Novel clip applicator for minimally invasive surgery

BackgroundLigation clips are used ubiquitously throughout minimally invasive surgery for apposition of tissues. Their size limits their application beyond ligation of small tubular structures. A novel clip and clip applicator that allows for broad-area clamping and rotation has been developed by our team. The primary aim of this study is to provide preliminary data assessing tensile strength of the clip across apposed segments of bowel.MethodsA comparative study evaluating the maximum load (N) held across two apposed tissues by (a) our novel broad-area clip and (b) a conventional commercial clip was performed. Two sections of porcine bowel were clamped together and the maximum load (N) was measured using a tensile strength material testing machine. A preliminary experiment comparing staple line leak pressures in a porcine model ± clip enforcement of staple line was also conducted. p < 0.05 determined statistical significance.ResultsTwenty-four samples (intervention = 15; control = 9) of porcine bowel annealed by surgical clips were tested. The mean maximum force withheld by the bowel and staples was greater for our novel clip design (2.043 ± 0.831 N) than the control clip (1.080 ± 0.466 N, p = 0.004). Ten staple line (intervention = 5; control = 5) pressures of porcine bowel were measured. There was no statistically significant difference between the leak pressures with clip reinforcement (84.8 mmHg; range 71.8–109.8 mmHg), or without (54.1 mmHg; range 26.3–98.9 mmHg).ConclusionThese preliminary results suggest that our novel clip is able to withstand higher tensile force across tissues compared to a leading commercial clip. A small preliminary trial of effect on leak pressures demonstrated no statistical significance; however, increasing reliability of staple line deformation may be a clinically important finding. Whilst further iteration of product design and clinical testing is required, this product may occupy an important clinical niche through staple line reinforcement, enterotomy closure and other applications.

The Positive Effects of the Human Amniotic Membrane on the Healing of Staple Line After Sleeve Gastrectomy Applied Long-Evans Rat Model.

The staple line leakage is a dangerous complication of sleeve gastrectomy. Various strategies have been tried to reduce the leakage risk. The amniotic membrane (AmM) is the inner layer of the placental membranes and has anti-inflammatory, anti-fibrosis, and anti-scarring effects, and it also has lower immune characteristics which are another essential characteristic of AmM concerning its utility for grafting. In this study, we aimed to investigate the impact of AmM on the staple line healing process of sleeve gastrectomy model in rats. We used twenty-eight Long-Evans rats in this study. Sleeve gastrectomy was performed with tristapler. Fourteen rats served as controls, AmM was applied staple line of the other fourteen. Fourteen animals were sacrificed (seven from the AmM applied group and the other seven from the control group) on the third postoperative day. And, the other fourteen animals were sacrificed (seven from the AmM applied group and seven from the control group) on the seventh postoperative day. The tissue around the staple line was evaluated microscopically and macroscopically, bursting pressures and hydroxyproline levels were also measured. The bursting pressure and hydroxyproline measurements of the AmM applied group was significantly higher on the seventh postoperative day (p = 0.015, p = 0.012) Fibroblast activity and neoangiogenesis of the AmM applied group was also significantly higher on the seventh postoperative day (p = 0.004, p = 0.002). This study showed that covering of staple line of sleeve gastrectomy model in rats significantly provided higher bursting pressures and increased hydroxyproline levels, fibroblast activity, and neoangiogenesis which may potentially lead a better staple line healing. We think further investigations are needed on this issue.

Bariatric Surgery Is Efficacious and Improves Access to Transplantation for Morbidly Obese Renal Transplant Candidates.

The surgical risk of morbidly obese patients is high and even higher for kidney transplant candidates. A BMI > 35-40kg/m2 is often a contraindication for that surgery. The safety, feasibility, and outcome of bariatric surgery for those patients are inconclusive. We conducted a retrospective chart review of prospectively collected data on morbidly obese renal transplant candidates who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in our institution between January 2009 and September 2017. The reported outcome included body weight and graft status after a mean follow-up of 47months (range 0.5-5years). Twenty-four patients (8 females, 16 males, average age 54years, average preoperative BMI 41kg/m2 [range 35-51]) underwent LSG (n = 17) or LRYGB (n = 7). Sixteen of them (67%) proceeded to kidney transplantation. Of the 8 pre-transplant and post-bariatric surgery patients, 5 are on the waitlist, and 2 patients died (one of staple line leakage, and one from sepsis unrelated to the bariatric surgery). The average time from bariatric surgery to transplantation was 1.5years (range 1month to 4.3years). The average pre-transplantation BMI was 28kg/m2 (range 19-36). The mean percentage of excess weight loss was 66% (n = 21), and the total percentage of weight loss was 29% (n = 21). Comorbidities (type 2 diabetes, hypertension, and dyslipidemia) improved significantly following both surgical approaches. LSG and LRYGB appear to effectively address obesity issues before kidney transplantation and improve surgical access. Morbidly obese transplant candidates would benefit from prior bariatric surgery.

Endoscopic Internal Drainage Coupled to Prompt External Drainage Mobilization Is an Effective Approach for the Treatment of Complicated Cases of Sleeve Gastrectomy.

Despite advances in treating gastric staple line leaks after bariatric surgical procedures, chronic leaks have been reported. Failure of their treatment frequently leads to radical surgery. We aimed to describe a strategy for preventing occurrence of chronic gastric leaks after complicated sleeve gastrectomy in patients necessitating relaparoscopy and external drainage as a first step of gastric leak management. Data from 14 consecutive patients admitted for gastric leak after laparoscopic sleeve gastrectomy were prospectively collected and retrospectively analyzed. Patients included underwent relaparoscopy and external drainage as first step of management. Median time to gastric leak detection was 4days. Emergency relaparoscopy allowed peritoneal lavage and external drainage placement next to the leak. Median time between surgery and endoscopic internal drainage (EID) was 4days. Progressive external drainage mobilization started after 2days. Control endoscopy was performed every 4weeks until healing. A median interval of 112days was necessary before healing in 13 patients. Thirteen patients (92.8%) had no gastric leak recurrence at 1year. In one patient, EID was considerably delayed and external drainage mobilization prolonged, leading to chronic gastric leak and total gastrectomy after 18months. This study reports for the first time a well-standardized protocol of early EID after relaparoscopy coupled to rapid external drainage removal for effectively treating complicated cases of sleeve gastrectomy. Bariatric surgeons should be aware of such therapeutic strategies and include them in their arsenal against postoperative gastric staple line leaks in severely obese patients.

Utility of 3-Week Follow-Up of Upper Gastrointestinal Study in Asymptomatic Patients Following Laparoscopic Sleeve Gastrectomy

Rationale and ObjectivesOne day following laparoscopic sleeve gastrectomy (LSG), routine practice has historically dictated that an upper gastrointestinal (UGI) study be performed to assess for staple line leak, clinically significant stenosis, or other complications requiring surgical revision. Recent literature has cast doubt on the utility of performing an UGI immediately following surgery due to its poor sensitivity in detecting leaks and hence referrals for this post-operative study have decreased. However, routine practice at our institution is to perform an UGI study at three weeks following LSG to assess for late complications despite a similar lack of evidence supporting the yield of this exam. The purpose of our study is to assess the utility and cost effectiveness of UGI exams in asymptomatic patients three weeks following LSG. Methods and MaterialsA retrospective chart review of patients who underwent LSG for obesity performed at our institution between January 2014 and October 2018 and subsequently had an UGI within two-four weeks following the surgery was conducted. ResultsA total of seventy three asymptomatic patients underwent an UGI study, of which no clinically significant stricture, leak or other complications were identified. Of the fifteen patients who were symptomatic between two-four weeks after surgery, twelve (80%) were found to have complications ranging from staple line leak or gastric narrowing. ConclusionsThe utility of UGI following LSG in the absence of symptoms is doubtful. Additionally, the added cost and radiation does not add value to the patient's care. We recommend UGI study utilization when there is a clinical suspicion for a complication.

Management of Staple Line Leaks Following Sleeve Gastrectomy-a Systematic Review.

A staple line leak following a sleeve gastrectomy is associated with significant morbidity and mortality. No uniform guideline or consensus exists with regard to the optimal treatment approach to managing a staple line leak. The objective of this systematic review is to assess the efficacy and success rates of the different treatment strategies for staple line leak following sleeve gastrectomy. A thorough search through four online electronic databases was conducted using predefined search criteria. Our primary outcome measure was to review the treatment options described in the management of the staple line leak following laparoscopic sleeve gastrectomy. Successful initial management was defined as the proportion of cases that were successfully treated using the first modality described, with no escalation to another treatment option. A total of 26 articles were included in this systematic review. Successful initial management of 62% was achieved in patients who underwent endoscopic management, 76% in those who underwent surgery and 82% in patients treated conservatively. A total of 7 patient deaths were noted, all of which were patients who underwent surgery as the initial management of their staple line leak. Prompt identification and adequate source control are crucial to successfully manage a staple line leak following sleeve gastrectomy. Treatment options are influenced by the clinical status of the patient. A stepwise treatment escalation approach is required to improve outcomes.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review

BackgroundStaple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM).MethodsThis systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options.ResultsOf the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).ConclusionsThis systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

The Impact of Staple Line Reinforcement Utilization on Bleeding and Leak Rates Following Sleeve Gastrectomy for Severe Obesity: a Propensity and Case-Control Matched Analysis.

Staple line reinforcement (SLR) is a commonly used technique during laparoscopic sleeve gastrectomy (SG) for severe obesity. There remains controversy over the potential benefit or risk associated with SLR. There are currently no consensus recommendations about SLR use. Its use is surgeon-dependent and remains controversial. To determine the impact of staple line reinforcement on staple line leak and bleeding rates after sleeve gastrectomy. Using the Metabolic and Bariatric Surgery Quality Improvement Program Participant User File (MBSQIP-PUF) database, we identified patients who had a SG in 2015 and 2016. SLR utilization status was used to create two cohorts. An unmatched cohort analysis was performed, and the outcomes were compared. A propensity score and case-control matched cohort analysis were then performed, and the outcomes were compared. Statistical analysis was performed with SPSS and SAS. Of the 189,173 SG cases identified, SLR utilization was noted in 127,521 (67.4%). In the unmatched analysis, bleeding and reoperation were significantly higher in the cohort without SLR utilization. In both propensity score and case-control matched analysis, bleeding and reoperation remained significantly higher in the cohort without SLR utilization. There was no difference in mortality and staple line leak rates between the cohorts. SLR significantly reduces bleeding and reoperation rates following SG and has no deleterious impact on staple line leak rate. While further prospective studies factoring in the SLR method and staple characteristics are needed, this large database analysis supports the use of routine SLR during SG to reduce the risk of perioperative bleeding and reoperation.

Is it Necessary to Send the Sleeve Gastrectomy Specimens to Pathology?

Laparoscopic sleeve gastrectomy (LSG) has become more popular among other bariatric procedures. The histopathologic changes in the sleeve gastrectomy specimens have not been widely investigated among the Turkish population. The purpose of this study was to delineate these histopathologic findings of the LSG specimens of morbidly obese patients from a single center. A prospective database of all patients who have undergone LSG at a single center was reviewed. Demographic parameters, that is, sex, age, and body mass index were examined. The incidence of Helicobacter pylori, and other pathologic findings in the specimens were studied. In total, 253 patients who had undergone LSG between the period spanning from April 2012 to January 2017 were included in the study. The 183 patients were female individuals and 70 patients were male individuals. The mean age at the time of operation was 38.5 years (range, 18 to 65 y). The mean body mass index was 47.7 kg/m. The pathologic findings were H. pylori positivity in 69 patients (27%), chronic active gastritis in 52 patients (20.5%), chronic gastritis in 135 patients (53.4%), and intestinal metaplasia in 5 patients (2%), whereas normal histopathologic findings were observed in 65 patients (25.7%). As regards surgical complications, the mortality rate was 0%, the staple-line leak was observed in 2 patients (0.8%), and intra-abdominal hemorrhage occurred in 2 patients (0.8%). The majority of patients who underwent LSG had pathologic findings in the resected specimens. With regard to the high incidence of pathologic findings in this study, we conclude that it is essential to send the gastrectomy materials for pathologic investigation after sleeve gastrectomy.

Effects and results of fibrin sealant use in laparoscopic sleeve gastrectomy

Background: Leakage and bleeding after LSG are very serious feared complications. The aim of this study was to review the clinical evidence after using fibrin sealant in standard LSG.Methods: Morbidly obese patients who underwent standard technique of LSG with using fibrin sealant were included in the study. Data concerning patient demographic variables [age, gender, body mass index (BMI, kg/m2), and comorbid conditions], previous surgeries, postoperative complications and postoperative readmissions were collected.Results: In total, 100 patients who underwent LSG, 51.6 % of the patients had obesity-related comorbid conditions with a BMI >35 kg/m². The mean age of the patients was 42 ± 13 years. All operations were completed laparoscopically. The mean operative time was 60 ± 12 min. No leakage was detected in the intra-operative methylene blue test. The mean hospital stay was 5 ± 2 days. Staple-line leakage, twist and stricture were not observed.No mortality were noted.Conclusion: This retrospective study shows that bariatric surgeons should consider using standard surgical surgery in LSG to reduce postoperative complications. Fibrin glue is a reliable and useful tool for strengthening the staple line and can prevent potential twist of the stomach.

Safety and efficacy of outpatient sleeve gastrectomy: 2534 cases performed in a single free-standing ambulatory surgical center

BackgroundSleeve gastrectomy (SG) is currently the most widely performed operation for treatment of morbid obesity. SG leads to significant weight loss and reduction in weight related comorbidities. Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present results of 2,534 consecutive patients who underwent SG in an ASC. ObjectiveAssess the safety and efficacy of outpatient SG in a freestanding ASC. SettingFree-standing ASC, Eviva Bariatrics, Seattle WA. MethodsData was collected retrospectively for all patients undergoing SG from January 2008 – January 2018, n = 2,534. Revisional procedures were not excluded from this study. Patients were excluded from the ASC if they weighed >450 pounds, if anticipated surgery time was > 2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. ResultsMean age was 45.9 years. Mean preoperative body mass index (BMI) was 41.9. Mean operative time was 70 minutes. 30-day complications included 3 mortalities (0.12%), 60 (2.53%) re-admissions, 35 (1.42%), re-operations, and 31 (1.22%) direct transfers from the ASC to a nearby hospital. There were 25 staple line leaks (0.99%). There were no open conversions. At 6 months average excess body weight loss (EWL) was 56.3% and total weight loss (TWL) was 20.9% (n = 1,758/2,303). At 1 year, EWL was 70.1% and TWL was 26.4% (n = 1,199/2,125). ConclusionWith experienced surgeons, appropriate protocols, and a consistent operative team, SG can be performed safely in a free-standing ASC.

Complications of postlaparoscopic sleeve gastric resection: review of surgical technique.

Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner. This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm. On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%. The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

Laparoscopic Sleeve Gastrectomy After Orthotopic Liver Transplantation, Video Reported.

The immunosuppressive therapy for life after liver transplantation (LT) is considered as a risk factor for obesity. Seven percent of the transplanted patients develop severe or morbid obesity. The obesity induces non-alcoholic steatohepatitis (NASH), which is a major risk factor for liver cirrhosis and hepatocellular carcinoma, without forgetting the cardiovascular risk and the devastating impact of obesity on quality of life of the transplanted patients. Consequently, obesity exposes these patients to future transplant loss. Bariatric surgery has been proposed for transplant patients to reduce the obesity-related comorbidities and to improve survival. We report in this video the surgical technique of laparoscopic sleeve gastrectomy (LSG) after LT. We have performed between 2008 and 2017 the sleeve gastrectomy (SG) after LT in nine patients. Six procedures (66%) were performed totally by laparoscopy and three by upfront laparotomy. All the patients had a standard preoperative evaluation for obesity. All the procedures were assisted by a hepatic surgeon. Postoperatively patients were transferred to the liver ICU for 24h then to the liver unit ward. The median BMI was 41.9kg/m2 (range 38-46.1kg/m2). Median operative time was 120min (range, 90-240min). No intra-operative complications occurred. The median length of hospital stay was 7days (range, 4-81days). The postoperative course of the majority of the patients was uneventful except for one patient who develops a staple line leak. LSG after LT is technically feasible. Larger series are needed to improve the safety of the procedure in this high-risk population.

Realignment of a Surgical Gastric Sleeve Using the Apollo Endoscopic Suturing Platform in a Patient With Postoperative Persistent Nausea and Vomiting

Laparoscopic sleeve gastrectomy is a restrictive procedure without the malabsorptive component of gastric bypass or duodenal switch. Reported common complications include bleeding, stenosis, misalignment, staple line leaks, and severe regurgitate symptoms. This case represents an uncommon complication characterized by gastroesophageal junction outflow obstruction due to redundant tissue from post-surgical change in the fundus. Repair with complete resolution of symptoms was achieved by performing endoscopy gastroplasty with the Apollo overstitch suturing system. J Curr Surg. 2019;9(2-3):29-31 doi: https://doi.org/10.14740/jcs380

Perioperative complications of sleeve gastrectomy: Review of the literature.

Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.

Biologic staple line reinforcement for laparoscopic sleeve gastrectomy: A case series

BackgroundLaparoscopic Sleeve Gastrectomy (LSG) is currently the most common bariatric procedure worldwide. Staple Line Reinforcement (SLR) with biological or synthetic material has been recommended to reduce complications such as staple line bleeding and leakage following LSG. SLR devices have been studied and have shown varied results in reducing these complications. ObjectiveThe aim of this study was to evaluate the rate of postoperative bleeding and staple line leakage associated with LSG when using a SLR material made from porcine small intestinal submucosa. SettingCommunity Hospital. MethodsThis was a single surgeon retrospective case review of all patients who had undergone LSG to treat severe obesity at our institution between January 2012 and August 2016 and had their staple line reinforced with a SLR device made from porcine small intestinal submucosa. Postoperative complications within the 30-day postoperative window, including bleeding and staple line leakage, were recorded. ResultsA total of 722 procedures were performed (female, 77%; age, 48.7 ± 13.2 years; preoperative Body Mass Index, 43.9 ± 7.6 kg/m2). The mean operative time was 109 ± 40 min and average length of stay was 1.5 days. Postoperative bleeding was noted in 9 patients (1.2%); 2 patients (0.3%) required re-operation for bleeding. Four (0.6%) post-operative staple line leaks were recorded. There was one post-operative death of indeterminate etiology. ConclusionsStaple line reinforcement with porcine small intestinal submucosa has leak and bleed rates comparable to those reported for other staple line reinforcement devices.