Vertical Staple Line Research Articles

Influence of staple line number and configuration on the leakage of small intestinal functional end-to-end stapled anastomosis: An ex vivo study.

To determine the influence of the staple line configuration on the leakage of small intestinal functional end-to-end stapled anastomosis (FEESA). Experimental, ex vivo, randomized study. Jejunal segments (N=72) from 10 mature, canine cadavers. Jejunal segments (10 cm) were randomly assigned to a control group (8 segments) and 4 FEESA groups (16 segments/group (8 constructs/group)), according to the number of rows of staples used in the vertical (V) and transverse lines (T), respectively: Control, 2-row V/2-row T (2V/2T), 2-row V/3-row T (2V/3T), 3-row V/2-row T (3V/2T), 3-row V/3-row T (3V/3T). Initial leak pressure (ILP), maximum intraluminal pressure (MIP), and initial leakage location (ILL) were compared. The ILP (mean ± SD) for control segments, 2V/2T, 2V/3T, 3V/2T and 3V/3T were 321.38 ± 34.59, 32.88 ± 7.36, 50.13 ± 10.46, 34.38 ± 11.78, 69.88 ± 21.23 mmHg, respectively. All FEESAs initially leaked at lower pressures than intact segments. The only other differences detected between groups consisted of ILPs that were higher when FEESAs were closed with 3V/3T (69.88 ± 21.23 mmHg) than 2V/2T (32.88 ± 7.36, P < .001). Initial leakage occurred predominantly from the transverse staple line rather than the anastomotic crotch (P < .001). Placing 3 rows of staples in the transverse line (with or without a third row in the vertical staple line) improved resistance to leakage of FEESAs in normal cadaveric specimens. The addition of a third row of staples in the transverse line (with or without a third row in the vertical staple line) in FEESAs should be further investigated as a strategy to reduce intestinal leakage clinically.

Smaller Staple Height for Circular Stapled Gastrojejunostomy in Laparoscopic Gastric Bypass: Early Results in 1,074 Morbidly Obese Patients

Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial

Roux-en-Y gastric bypass (RYGB) is amongst the commonest surgical intervention for weight loss in obese patients. Gastrocutaneous fistula, which usually occurs along the vertical staple line of the pouch, is amongst its most alarming complications. Medical management comprised of wound drainage, nutritional support, acid suppression, and antibiotics may be ineffective in as many as a third of patients with this complication. We present outcomes after endoscopic application of SurgiSIS, which is a novel biomaterial for the treatment of this complication. A case series of 25 patients. Twenty-five patients who had failed conservative medical management of gastrocutaneous fistula after RYGB underwent endoscopic application of SurgiSIS--an acellular fibrogenic matrix biomaterial to help fistula healing. Fistula closure as assessed by upper gastrointestinal imaging and endoscopic examination. In patients who had failed medical management lasting 4-25 (median, 7) weeks, closure of the fistulous tract was successful after one application in six patients (30%), two applications in 11 patients (55%), and three applications in three patients (15%). There were no procedure-related complications. Endoscopic application of SurgiSIS-an acellular fibrogenic matrix--is safe and effective for the treatment of gastrocutaneous fistula after RYGB.

Transvaginal Single Access “Pure” NOTES Sleeve Gastrectomy Using a Deployable Magnetically Anchored Video Camera

Introduction: Laparoscopic sleeve gastrectomy is a new operation for morbid obesity that involves a vertical gastric resection, leaving a narrow tube (150-200 cc) along the lesser curve. This operation avoids anastomoses required for gastric bypass and has resulted in effective weight loss. The goal of this study was to determine the feasibility of transvaginal NOTES sleeve gastrectomy without laparoscopic assistance. Methods: Non-survival procedures were conducted in pigs (n = 2, 34-35 kg). Through a vaginotomy created under direct vision, a rigid access tube (23 mm inner diameter, 40 cm long) with dual instrument seals (used to maintain a CO2 pneumoperitoneum) was inserted into the peritoneal cavity. A single or dual channel gastroscope was used for initial visualization and a deployable magnetically anchored video camera (onboard light source) was used for visualization during subsequent portions of the procedure. The stomach was retracted using flexible endoscopic graspers, a new long (70 cm) articulating rigid grasper (5 mm diameter), magnetically anchored maneuverable graspers, T-tag fasteners, and traction sutures placed with prototype articulating flexible and rigid suturing devices (9 mm diameter). An articulating rigid linear stapler (13 mm diameter) with an elongated shaft (70 cm) was used for stomach and vascular division. Results: No laparoscopic assistance was used. During the first procedure, only a single gastric stapler application was achieved due to retraction difficulties despite the use of several grasper strategies and 3 percutaneous T-tags. In the second procedure, only a single percutaneous T-tag was used; traction sutures passed through the access port and held externally facilitated adequate retraction and complete gastric division using a total of 6 stapler cartridges (60mm length). Two vascular cartridges (45 mm length) were used for short gastric vessel division. The deployable video camera provided superior imaging of the operative field compared to the flexible endoscope. Blood loss was minimal (<30 cc) and no intraabdominal injuries were detected at autopsy. Ex-vivo evaluation revealed an intact vertical staple line with no leaks or compromise of the esophagus or gastric outlet and a remnant volume of 500 cc.Conclusions: This is the first study to document the feasibility of a transvaginal sleeve gastrectomy using a single access “pure” NOTES approach. The deployable video camera improved visualization and allowed maximal use of the limited access space for therapeutic instruments. Further refinements in instrumentation and techniques are expected to provide greater accuracy in achieving the desired degree of gastric resection.

Endoscopic removal of eroded bands in vertical banded gastroplasty: a novel use of endoscopic scissors (with video)

Vertical banded gastroplasty (VBG) as a surgical therapy for morbid obesity was first described in 1982. VBG involves partitioning the stomach with a vertical staple line and restricting the outlet pouch with a Gortex band. Complications of VBG include partial and total erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Band erosion occurs after surgery in 1% to 3% of patients, and patients may present with symptoms of obstruction, weight gain, nausea, pain, and bleeding. Unless a band has freely eroded from the stomach wall, allowing spontaneous elimination or simple endoscopic retrieval, surgical removal has been required heretofore. Previous attempts at endoscopic removal of eroded bands have included the use of neodymium-yttrium aluminum garnet laser ablation and other electrosurgical devices. Endoscopic scissors transection to remove an eroded laparoscopic band has been described in Europe but has not been performed in the United States. In this series, we describe the endoscopic removal of partially eroded bands embedded in the gastric wall by using flexible endoscopic scissors to sever and subsequently withdraw the bands endoscopically through the mouth. Eroded gastric bands have been safely removed endoscopically in 2 ambulatory outpatients. Case series. Tertiary-care academic center. Efficacy and safety. Highly selected motivated patient population.

Pouch-related fistula following restorative proctocolectomy.

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.

Five-year results of laparoscopic vertical banded gastroplasty in the treatment of massive obesity.

Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (LVBG) in 154 obese patients with a follow-up of 12-60 months. 154 massively obese patients (132 female) with a mean +/- SEM body mass index (BMI) of 43.4 +/- 0.6 kg/m2 were followed prospectively for an average of 31.7 +/- 1.4 months. LVBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line and a stretched polytetrafluoroethylene (Gore-tex) band was used to reinforce the outlet. After the first 67 cases, the procedure was altered so that a 5-cm length was marked on the band. Conversion to open surgery was performed in 33 cases. All patients lost weight. At 60 months follow-up, the postoperative weight was similar in the open and laparoscopic group.The subjects where 5 cm length was marked on the band had a significantly better weight loss at 36 months (30.4 +/- 1.2). Both early (< 1 month postoperative) and late (> 1 month postoperative) complications were more common in the group converted to open surgery. Postoperative stay was shorter in the laparoscopic group. LVBG can be performed safely and results in shorter postoperative stay than open VBG. With adherence to surgical technique (5-cm band circumference), weight-loss is maintained at an adequate level. Complications after LVBG do not exceed open VBG.

60 reoperations on 890 patients after gastric restrictive surgery.

Since 1988 we performed gastric restriction operations on 890 patients; 60 required subsequent re-operation. The Molina non-adjustable band was discontinued early because of a high percentage of re-operations. Between 1992 and 1995, we performed the Mason vertical banded gastroplasty (VBG) using a 9-cm long vertical staple-line, with a re-operation rate of 15%. Since 1996, we have been performing a 6-cm long vertical staple-line, with a re-operation rate of 0.7%. The MacLean VBG also had a low re-operation rate (0.9%), but the seriousness of its most dangerous complication, perioperative cardia fistula, limited our use of this method to specifically selected cases. With adjustable banding, we have used the Swedish band which produced a low re-operation rate (2.1%), consisting of relatively simple corrective procedures. The re-operations produced results similar to those of first-time operations in terms of weight loss and nutritional status. In particular, after 3 years, re-operated patients had similar weight to those who had been operated upon with the same method initially. When the surgical procedure was selected with greater astuteness and modified appropriately, the re-operation rate decreased from 17% in the period 1992 to 1995, to 1% in the period 1996 to 2000.

"No punch" technique of laparoscopic vertical banded gastroplasty for morbid obesity.

This report describes the technical details and an initial evaluation of laparoscopic vertical gastroplasty modified for morbid obesity. After a surgical experience in 150 patients with open vertical banded gastroplasty (Mason's procedure), it was decided to perform a modified banded vertical gastroplasty. Six patients were treated by this laparoscopic approach in 1997-1998. All patients were women with a mean age of 28 years (range 20-46). The mean body weight was 128 kg (range 105-146), and the mean BMI was 42.7 kg/m2 (range 35.6-53.0). Four or five 10- or 12-mm trocars were used. For all the dissection we used atraumatic ultracision (harmonic scalpel). In this procedure the technique of laparoscopic gastroplasty is performed without a circular gastric window. During the operation, 3 omental openings were made and the vertical staple-line was constructed by using a 30-mm 3-row linear stapler twice, establishing the gastric pouch. The outflow stoma was reinforced by a Gore-Tex band and calibrated to have an internal diameter of 10-15 mm. The band was sutured to itself. There were no deaths or complications. Operating time was 200 min (150-240). The nasogastric tube was removed at 1-2 days. The postoperative course was characterized by normal respiratory function and minimal pain in all cases. Patients were discharged 5-6 days after operation. Our technique excluded the circular gastric window (i.e., "no-punch") technique in the development of an effective and simple laparoscopic procedure to treat morbid obesity.

Three-year results of laparoscopic vertical banded gastroplasty.

Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (lap VBG) in 60 obese patients. 60 massively obese patients (50 female) with a mean +/- SEM body mass index (BMI) of 44.4 +/- 1.0 kg/m2 were followed up prospectively for an average of 23.0 +/- 1.5 months. Lap VBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line, and a stretched polytetrafluoroethylene (Gore-Tex) band was used to reinforce the outlet. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery. Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m2 (37.7-65.7) and 5 days (3-13), and 41.9 kg/m2 (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m2 (24.6-50.7) (n = 9) in the open group and 37.0 kg/m2 (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m2 (33.8-65.8) and 41.2 kg/m2 (32.4-57.8). Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.

Results of the surgical treatment of obesity

A prospective, randomized trial comparing vertical banded gastroplasty (VBG) and vertical gastric bypass (GB) for obesity was completed in 106 patients who did not differ in baseline body mass index (BMI = kg/m2) or length of follow-up. The goal of this surgery was to return patients to within 50% of their ideal weight, i.e., a body mass index less than 35 kg/m2, and to accomplish this while maintaining a low risk for malnutrition as well as other morbidity and mortality. Success was defined as a BMI less than 35 kg/m2 because the mortality risk increases rapidly above this degree of obesity. Surgical failures were encountered in 43% of the 54 patients in the VBG group, all of whom had division between the vertical staple lines. The main causes of failure were stenosis and enlargement of the gastroplasty orifice. Surgery failed in 23% of the GB-treated patients, due to perforation of the vertical staple line. An isolated gastric bypass (IGB) not dependent on staples was performed as the remedial operation for the failures of both VBG and GB. IGB was significantly better than VBG or GB, with a success rate of 83% compared with 39% for VBG and 58% for GB. Subsequent experience since completion of this randomized trial in 54 consecutive patients supports IGB for primary, as well as remedial, operations for the morbidly obese (BMI = 40 to 50 kg/m2), as well as for patients who are super obese (BMI greater than 50 kg/m2).

Vertical banded gastroplasty for the treatment of morbid obesity.

We report the technique and results of vertical banded gastroplasty in 86 morbidly obese patients. At 12 months, the patients had lost a mean of 57% of their excess body weight; 36 months, they had lost 70%. The most severe early complication was perforation of the esophagus. Other complications included disruption of the vertical staple line in three cases and migration of the mesh band. We were able to achieve satisfactory weight reduction in all patients over a period of 36 months. In view of the good results, reduced morbidity, and absence of mortality, we feel that vertical banded gastroplasty is the surgical treatment of choice for morbid obesity at present.