Obesity Surgery

, Volume 19, Issue 2, pp 166–172 | Cite as

Reinforcement Does Not Necessarily Reduce the Rate of Staple Line Leaks After Sleeve Gastrectomy. A Review of the Literature and Clinical Experiences

  • Bo Chen
  • Andreas Kiriakopoulos
  • Dimitrios Tsakayannis
  • Mitchell S. Wachtel
  • Dimitrios Linos
  • Eldo E. Frezza
Research Article
First Online:
Received:
Accepted:

Abstract

Background

Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause.

Methods

The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks.

Results

Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41–3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures.

Conclusions

There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.

Keywords

Polytetrafluoroethylene Bovine pericardium Porcine small bowel Polyglycolic acid Trimethylene carbonate Calcium alginate sleeves Sleeve gastrectomy Complications Leaks Morbid obesity Staple line Review of literature 
This is a preview of subscription content, log in to check access.

References

  1. 1.
    Frezza EE. Laparoscopic vertical sleeve gastrectomy for morbid obesity. The future procedure of choice? Surg Today 2007;37:275–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Gumbs AA, Gagner M, Dakin G, et al. Sleeve gastrectomy for morbid obesity. Obes Surg 2007;17:962–9.CrossRefPubMedGoogle Scholar
  3. 3.
  4. 4.
    Givon-Madhala O, Spector R, Wasserberg N, et al. Technical aspects of laparoscopic sleeve gastrectomy in 25 morbidly obese patients. Obes Surg 2007;17:722–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Nguyen NT, Longoria M, Chalifoux S, et al. Bioabsorbable staple line reinforcement for laparoscopic gastrointestinal surgery. Surg Technol Int 2005;14:107–11.PubMedGoogle Scholar
  6. 6.
    Arnold W, Shikora SA. A comparison of burst pressure between buttressed versus non-buttressed staple-lines in an animal model. Obes Surg 2005;15:164–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Downey DM, Harre JG, Dolan JP. Increased burst pressure in gastrointestinal staple-line using reinforcement with a bioprosthetic material. Obes Surg 2005;15:1379–83.CrossRefPubMedGoogle Scholar
  8. 8.
    Franklin ME Jr, Ramila GP, Treviño JM, et al. The use of bioabsorbable staple line reinforcement for circular stapler (BSG “SeamGuard”) in colorectal surgery: initial experience. Surg Laparosc Endosc Percutan Tech 2006;16:411–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Saito Y, Omiya H, Shomura Y, et al. A new bioabsorbable sleeve for staple-line reinforcement: report of a clinical experience. Surg Today 2002;32:297–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Angrisani L, Lorenzo M, Borrelli V, et al. The use of bovine pericardial strips on linear stapler to reduce extraluminal bleeding during laparoscopic gastric bypass: prospective randomized clinical trial. Obes Surg 2004;14:1198–202.CrossRefPubMedGoogle Scholar
  11. 11.
    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;18:487–96.CrossRefPubMedGoogle Scholar
  12. 12.
    Wu EC, Barba CA. Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg 2000;10:7–13, discussion 14.CrossRefPubMedGoogle Scholar
  13. 13.
    Consten EC, Gagner M, Pomp A, et al. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttress absorbable polymer membrane. Obes Surg 2004;14:1360–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Serra C, Baltasar A, Andreo L, et al. Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg 2007;17:866–72.CrossRefPubMedGoogle Scholar
  15. 15.
    Frezza EE, Reddy S, Gee L, Wachtel MS. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. In press, 2008.Google Scholar
  16. 16.
    Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4:33–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Bernante P, Foletto M, Busetto L, et al. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding. Obes Surg 2006;16:1327–30.CrossRefPubMedGoogle Scholar
  18. 18.
    Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrectomy (LSG): review of a new bariatric procedure and initial results. Surg Technol Int 2006;15:47–52.PubMedGoogle Scholar
  19. 19.
    Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859–63.CrossRefPubMedGoogle Scholar
  20. 20.
    Han MS, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005;15:1469–75.CrossRefGoogle Scholar
  21. 21.
    Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 2005;15:1124–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514–23, discussion 524.CrossRefPubMedGoogle Scholar
  24. 24.
    Consten EC, Dakin GF, Gagner M. Intraluminal migration of bovine pericardial strips used to reinforce the gastric staple-line in laparoscopic bariatric surgery. Obes Surg 2004;14:549–54.CrossRefPubMedGoogle Scholar
  25. 25.
    Champion JK, Williams MD. Prospective randomized comparison of linear staplers during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13:855–9, discussion 860.CrossRefPubMedGoogle Scholar
  26. 26.
    Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg 2004;14:1290–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Liu CD, Glantz GJ, Livingston EH. Fibrin glue as a sealant for high-risk anastomosis in surgery for morbid obesity. Obes Surg 2003;13:45–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Pinheiro JS, Correa JL, Cohen RV, et al. Staple line reinforcement with new biomaterial increased burst strength pressure: an animal study. Surg Obes Relat Dis 2006;2:397–9, discussion 400.CrossRefPubMedGoogle Scholar
  29. 29.
    Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.PubMedGoogle Scholar
  30. 30.
    Miller JI Jr, Landreneau RJ, Wright CE, et al. A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections. Ann Thorac Surg 2001;71:319–22, discussion 323.CrossRefPubMedGoogle Scholar
  31. 31.
    Assalia A, Ueda K, Matteotti R, et al. Staple-line reinforcement with bovine pericardium in laparoscopic sleeve gastrectomy: experimental comparative study in pigs. Obes Surg 2007;17:222–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Shikora SA. The use of staple-line reinforcement during laparoscopic gastric bypass. Obes Surg 2004;14:1313–20.CrossRefPubMedGoogle Scholar
  33. 33.
    Shikora SA, Kim JJ, Tarnoff ME. Reinforcing gastric staple-lines with bovine pericardial strips may decrease the likelihood of gastric leak after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13:37–44.CrossRefPubMedGoogle Scholar
  34. 34.
    Oey I, Waller DA. Metalloptysis: a late complication of lung volume reduction surgery. Ann Thorac Surg 2001;71:1694–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Provencher S, Deslauriers J. Late complication of bovine pericardium patches used for lung volume reduction surgery. Eur J Cardiothorac Surg 2003;23:1059–61.CrossRefPubMedGoogle Scholar
  36. 36.
    Fischel RJ, McKenna RJ. Bovine pericardium versus bovine collagen to buttress staples for lung reduction operations. Ann Thor Surg 1998;65:217–9.CrossRefGoogle Scholar
  37. 37.
    Thomas P, Massard G, Porte H, et al. A new bioabsorbable sleeve for lung staple-line reinforcement (FOREseal): report of a three-center phase II clinical trial. Eur J Cardiothorac Surg 2006;29:880–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Consten EC, Gagner M. Staple-line reinforcement techniques with different buttressing materials used for laparoscopic gastrointestinal surgery: a new strategy to diminish perioperative complications. Surg Technol Int 2004;13:59–63.PubMedGoogle Scholar
  39. 39.
    Murray KD, Ho CH, Hsia JY, et al. The influence of pulmonary staple line reinforcement on air leaks. Chest 2002;122:2146–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Vaughn CC, Vaughn PL, Vaughn CC 3rd, et al. Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 1998;13:259–65.CrossRefPubMedGoogle Scholar
  41. 41.
    Holcomb GW 3rd, Ostlie DJ, Miller KA. Laparoscopic patch repair of diaphragmatic hernias with Surgisis. J Pediatr Surg 2005;40:E1–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Schultz DJ. Porcine small intestine submucosa as a treatment for enterocutaneous fistulas. J Am Coll Surg 1994;194:541–3.CrossRefGoogle Scholar
  43. 43.
    Kini S, Gagner M, de Csepel J, et al. A biodegradable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report. Obes Surg 2001;11:469–73.CrossRefPubMedGoogle Scholar
  44. 44.
    Downey DM, Michel M, Harre JG, et al. Functional assessment of a new staple line reinforcement in lung resection. J Surg Res 2006;131:49–52.CrossRefPubMedGoogle Scholar
  45. 45.
    Downey DM, Harre JG, Pratt JW. Functional comparison of staple line reinforcements in lung resection. Ann Thorac Surg 2006;82:1880–3.CrossRefPubMedGoogle Scholar
  46. 46.
    Tucker JG, Copher JC, Reilly JP, et al. The use of bioabsorbable seamguard during laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2007;17:83–5.CrossRefPubMedGoogle Scholar
  47. 47.
    de la Portilla F, Zbar AP, Rada R, et al. Bioabsorbable staple-line reinforcement to reduce staple-line bleeding in the transection of mesenteric vessels during laparoscopic colorectal resection: a pilot study. Tech Coloproctol 2006;10:335–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Franklin ME Jr, Berghoff KE, Arellano PP, et al. Safety and efficacy of the use of bioabsorbable seamguard in colorectal surgery at the Texas endosurgery institute. Surg Laparosc Endosc Percutan Tech 2005;15:9–13.CrossRefPubMedGoogle Scholar
  49. 49.
    Miller KA, Pump A. Use of bioabsorbable staple reinforcement material in gastric bypass: a prospective randomized clinical trial. Surg Obes Relat Dis 2007;3:417–21, discussion 422.CrossRefPubMedGoogle Scholar
  50. 50.
    Goto T, Kawasaki K, Fujino Y, et al. Evaluation of the mechanical strength and patency of functional end-to-end anastomoses. Surg Endosc 2007;21:1508–11.CrossRefPubMedGoogle Scholar
  51. 51.
    Nguyen NT, Longoria M, Welbourne S, et al. Glycolide copolymer staple-line reinforcement reduces staple site bleeding during laparoscopic gastric bypass: a prospective randomized trial. Arch Surg 2005;140:773–8.CrossRefPubMedGoogle Scholar
  52. 52.
    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.PubMedGoogle Scholar
  53. 53.
    Póvoas HP, Vilas-Bôas ML. Staplerless laparoscopic gastric bypass: not so fast. Obes Surg 2006;16:1115.CrossRefPubMedGoogle Scholar
  54. 54.
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y—500 patients: technique and results, with 3–60 month follow-up. Obes Surg 2000;10:233–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Simper SC, Erzinger JM, Smith SC. Comparison of laparoscopic linear staplers in clinical practice. Surg Obes Relat Dis 2007;3:446–50. discussion 450–1.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2008

Authors and Affiliations

  • Bo Chen
    • 1
  • Andreas Kiriakopoulos
    • 2
  • Dimitrios Tsakayannis
    • 2
  • Mitchell S. Wachtel
    • 3
  • Dimitrios Linos
    • 2
  • Eldo E. Frezza
    • 4
  1. 1.Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
  2. 2.First Surgical Clinic, Department of Surgery‘‘Hygeia’’ HospitalAthensGreece
  3. 3.Department of PathologyTexas Tech University Health Sciences CenterLubbockUSA
  4. 4.Department of SurgeryUniversity of Alabama, VAMC Surgical Service 112BirminghamUSA

Personalised recommendations