Obesity Surgery

, Volume 27, Issue 12, pp 3209–3214 | Cite as

Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height—an Observational Cohort Study

Fundus Wall Thickness and Leaks
  • Clara BoekerEmail author
  • Julian Mall
  • Christian Reetz
  • Kamil Yamac
  • Ludwig Wilkens
  • Christine Stroh
  • Hinrich Koehler
Original Contributions



Staple line leakage is a well-known complication after laparoscopic sleeve gastrectomy (LSG). Gastric wall thickness and the staple height may be determining factors for the occurrence of insufficiencies. To investigate this problem, an observational cohort study was carried out. Investigation concentrated on the gastroesophageal junction close to the angle of His, since this area is at highest risk for a leakage.


Fundus wall thickness of 141 specimens after LSG was measured by light microscopy at a predetermined location by a blinded pathologist. Furthermore, fundus wall thickness was compared with demographic data, clinical outcome, and the rate of insufficiencies.


One hundred forty-one patients, 38 male and 103 female undergoing LSG, between January 2014 and July 2015 were included in the study. Male gender was associated with thicker gastric fundus wall. Overall leak rate was 2.1% (3/141). Median wall thickness of the 3 patients with detected leaks in the study group was thinner compared to the non-leak group (2810 vs. 3249 μm, respectively).


Only male gender correlated with higher wall thickness of the fundus. The fact that all three patients who developed a leak were female, and the fundus of female patients as well as those of the leak group was thinner, indicates that wall thickness may have an impact on the rate of staple line leakage. Further studies with larger patient cohorts are needed.


Sleeve gastrectomy Leak Staple height Wall thickness Risk factors 



We would like to acknowledge the team of the Department of General, Visceral, Vascular and Bariatric Surgery and the operating room staff at Klinikum Nordstadt and the Department of Pathology of the Klinikum Nordstadt for their assistance and help.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that there is no conflict of interest.


All procedures and collection of patient data followed the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat dis. 2009;5(4):469–75.CrossRefPubMedGoogle Scholar
  2. 2.
    Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.Google Scholar
  3. 3.
    Rosenthal RJ, International Sleeve Gastrectomy Expert Panel. 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.CrossRefPubMedGoogle Scholar
  4. 4.
    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.CrossRefPubMedGoogle Scholar
  5. 5.
    Al Hajj GN, Haddad J. Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs oversewing. Obes Surg. 2013;23(11):1915–21.CrossRefPubMedGoogle Scholar
  6. 6.
    Knapps J, Ghanem M, Clements J, et al. A systematic review of staple-line reinforcement in laparoscopic sleeve gastrectomy. JSLS. 2013;17(3):390–9.Google Scholar
  7. 7.
    Kassir R, Blanc P, Amor IB, et al. Division of the stomach and checking on haemostasis for performing sleeve gastrectomy. Points of controversy. Obes Surg. 2015;25(3):537–8.Google Scholar
  8. 8.
    Benedix F, Benedix D, Knoll C, et al. Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes Surg. 2014;24(10):1610–6.Google Scholar
  9. 9.
    Wölnerhanssen B, Peterli R. State of the art: sleeve gastrectomy. Dig Surg. 2014;31:40–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg. 2004;14(10):1290–8.Google Scholar
  11. 11.
    Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol. 2014;20(38):13904–10.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Basso N, Casella G, Rizzello M, et al. Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases. Surg Endosc. 2011;25(2):444–9.Google Scholar
  13. 13.
    Stroh C, Köckerling F, Volker L, et al., Obesity Surgery Working Group; Competence Network Obesity. Results of more than 11,800 sleeve gastrectomies. Data analysis of the German Bariatric Surgery Registry. Ann Surg. 2016;263(5):949–55.Google Scholar
  14. 14.
    Ferrer-Márquez M, Belda-Lozano R, Ferrer-Ayza M. Technical controversies in laparoscopic sleeve gastrectomy. Obes Surg. 2012;22(1):182–7.CrossRefPubMedGoogle Scholar
  15. 15.
    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
  16. 16.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Rawlins L, Rawlins MP, Donovan T. Human tissue thickness measurements from excised sleeve gastrectomy specimens. Surg Endosc. 2014;28(3):811–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Kunisaki C, Makino H, Takagawa R, et al. Prospective randomized controlled trial comparing the use of 3.5-mm and 4.8-mm staples in gastric surgery. Hepato-Gastroenterology. 2008;55(86–87):1943–7.Google Scholar
  19. 19.
    Nakayama S, Hasegawa S, Nakayama S, et al. The importance of precompression time for secure stapling with a linear stapler. Surg Endosc. 2011;25(7):2382–6.Google Scholar
  20. 20.
    Deutsche Adipositas Gesellschaft (DAG). Interdisziplinären Leitlinie der Qualität S3 zur “Prävention und Therapie der Adipositas”. Version 2.0 (April 2014).
  21. 21.
    Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). S3-Leitlinie: Chirurgie der Adipositas. 2010.
  22. 22.
    Mulisch M, Welsch U, editors. Romeis. Mikroskopische Technik. 18th ed. Heidelberg: Spektrum; 2010.Google Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of General, Visceral, Vascular and Bariatric SurgeryKlinikum NordstadtHannoverGermany
  2. 2.Department of PathologyKlinikum NordstadtHannoverGermany
  3. 3.Department of General, Visceral and Children SurgerySRH Wald-Klinikum GeraGeraGermany
  4. 4.Department of SurgeryHerzogin Elisabeth HospitalBraunschweigGermany

Personalised recommendations