Abstract
Background
The purpose of this paper was to search for predictive factors for proximal leakage after laparoscopic sleeve gastrectomy (LSG) in a large cohort from a single referral center.
Materials and Methods
One thousand seven hundred and thirty-eight patients, collected in a prospectively held database from 2008 to 2016, were retrospectively analyzed. The correlation between postoperative leakage and both preoperative (age, gender, height, weight, BMI, and obesity-related morbidities) and operative variables (the distance from pylorus at which the gastric section was started, operative time, experience of surgeons who performed the LSG, and the surgical materials used) was analyzed. The experience of the surgeons was calculated in the number of LSGs performed. The surgical materials considered were stapler, cartridges, and reinforcement of the suture.
Results
Proximal leakage was observed in 45 patients out of 1738 (2.6%). No correlation was found between leakage and the preoperative variables analyzed. The operative variables that were found to be associated with lower incidence of leakage at the multivariate analysis (p < 0.05) were the reinforcement of the staple line (or overriding suture or buttressing materials) and the experience of the surgeons. A distance of less than 2 cm from the pylorus resulted to be significantly related to a higher incidence of fistula at the univariate analysis.
Conclusions
In this large consecutive cohort study of LSG, proximal staple line reinforcement (buttress material or suture) reduced the risk of a leak. The risk of a proximal leak was much higher in the surgeons first 100 cases, which has implications for training and supervision during this “learning curve” period.
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References
Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007. Obes Surg. 2008;18(5):487–96.
Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis. 2009;5(4):476–85.
Deitel M, Gagner M, Erickson AL, et al. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7(6):749–59.
Gagner M, Deitel M, Erickson AL, et al. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013;23(12):2013–7.
Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2016;12(4):750–6.
Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.
Juodeikis Ž, Brimas G. Long-term results after sleeve gastrectomy: a systematic review. Surg Obes Relat Dis. 2017;13(4):693–9.
Gadiot RP, Biter LU, van Mil S, et al. Long-term results of laparoscopic sleeve gastrectomy for morbid obesity: 5 to 8-year results. Obes Surg. 2017;27(1):59–63.
Sakran N, Raziel A, Goitein O, et al. Laparoscopic sleeve gastrectomy for morbid obesity in 3003 patients: results at a high-volume bariatric center. Obes Surg. 2016;26(9):2045–50.
Wang X, Chang XS, Gao L, et al. Effectiveness of laparoscopic sleeve gastrectomy for weight loss and obesity-associated co-morbidities: a 3-year outcome from Mainland Chinese patients. Surg Obes Relat Dis. 2016;12(7):1305–11.
Gagner M, Buchwald JN. Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis. 2014;10(4):713–23.
Berger ER, Clements RH, Morton JM, et al. The impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP). Ann Surg. 2016;264(3):464–73.
Stroh C, Birk D, Flade-Kuthe R, et al. Results of sleeve gastrectomy—data from a nationwide survey on bariatric surgery in Germany. Obes Surg. 2009;19(5):632–40.
Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20. discussion 420-2
Jurowich C, Thalheimer A, Seyfried F, et al. Gastric leakage after sleeve gastrectomy-clinical presentation and therapeutic options. Langenbeck's Arch Surg. 2011;396(7):981–7.
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26(6):1509–15.
Stroh C, Köckerling F, Volker L, et al. Results of more than 11,800 sleeve gastrectomies: data analysis of the German Bariatric Surgery Registry. Ann Surg. 2016;263(5):949–55.
Iossa A, Abdelgawad M, Watkins BM, et al. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbeck's Arch Surg. 2016;401(6):757–66.
Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg. 2004;14(10):1290–8. Review. Erratum in: Obes Surg. 2013 Dec;23(12):2124
Saber AA, Azar N, Dekal M, et al. Computed tomographic scan mapping of gastric wall perfusion and clinical implications. Am J Surg. 2015;209(6):999–1006.
Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19.
Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9.
Elariny H, González H, Wang B. Tissue thickness of human stomach measured on excised gastric specimens from obese patients. Surg Technol Int. 2005;14:119–24.
Huang R, Gagner M. A thickness calibration device is needed to determine staple height and avoid leaks in laparoscopic sleeve gastrectomy. Obes Surg. 2015;25(12):2360–7.
Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27(1):240–5.
Parikh M, Issa R, McCrillis A, et al. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg. 2013;257(2):231–7.
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Cesana, G., Cioffi, S., Giorgi, R. et al. Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1738 Consecutive Procedures. OBES SURG 28, 627–635 (2018). https://doi.org/10.1007/s11695-017-2907-z
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DOI: https://doi.org/10.1007/s11695-017-2907-z