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

  • Matthew Cunningham-Hill
  • Michael Mazzei
  • Huaqing Zhao
  • Xiaoning Lu
  • Michael A. EdwardsEmail author
Original Contributions



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.

Study Aim

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.


Sleeve gastrectomy Staple line reinforcement Leak rate Bleeding rate 


Compliance with ethical standards

Conflict of Interest

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Ethical Approval Statement

This article does not contain any studies with human participants or animals performed by any of the authors. This is a retrospective review of a nationally available, clinical database containing only deidentified data. The dataset does not have any variables that would allow for patient, surgeon, or institution identification. For this type of study, neither an institutional review board approval nor formal consent was required.


  1. 1.
    WHO. Obesity and overweight. WHO. Published 2018, Accessed August 21, 2018
  2. 2.
    Peterli R, Wölnerhanssen BK, Peters T, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial. JAMA. 2018;319(3):255–65.CrossRefGoogle Scholar
  3. 3.
    Salminen P, Helmiö M, Ovaska J, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA. 2018;319(3):241–54.CrossRefGoogle Scholar
  4. 4.
    Kang JH, Le QAJM. Effectiveness of bariatric surgical procedures: a systematic review and network meta-analysis of randomized controlled trials. Medicine (Baltimore). 2017;96(46):e8632.CrossRefGoogle Scholar
  5. 5.
    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.CrossRefGoogle Scholar
  6. 6.
    Abraham A, Ikramuddin S, Jahansouz C, et al. Trends in bariatric surgery: procedure selection, revisional surgeries, and readmissions. Obes Surg. 2016;26(7):1371–7.CrossRefGoogle Scholar
  7. 7.
    Varela JE, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015;11(5):987–90.CrossRefGoogle Scholar
  8. 8.
    Durmush EK, Ermerak G, Durmush D. Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter? Obes Surg. 2014;24(7):1109–16.CrossRefGoogle Scholar
  9. 9.
    Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2016;12(4):750–6.CrossRefGoogle Scholar
  10. 10.
    Giannopoulos GA, Tzanakis NE, Rallis GE, et al. Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis. Surg Endosc. 2010;24(11):2782–8.CrossRefGoogle Scholar
  11. 11.
    Hoyuela C. Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity: a prospective study. World J Gastrointest Surg. 2017;9(4):109–17.CrossRefGoogle Scholar
  12. 12.
    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.CrossRefGoogle Scholar
  13. 13.
    Lee JH, Nguyen Q-N, Le QA. Comparative effectiveness of 3 bariatric surgery procedures: Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy. Surg Obes Relat Dis. 2016;12(5):997–1002.CrossRefGoogle Scholar
  14. 14.
    Maciejewski ML, Arterburn DE, Van Scoyoc L, et al. Bariatric surgery and long-term durability of weight loss. JAMA Surg. 2016;151(11):1046–55.CrossRefGoogle Scholar
  15. 15.
    Nassour I, Almandoz JP, Adams-Huet B, et al. Metabolic syndrome remission after Roux-en-Y gastric bypass or sleeve gastrectomy. Diabetes, metabolic syndrome and obesity: targets and therapy. Diabetes Metab Syndr Obes. 2017;10:393–402.CrossRefGoogle Scholar
  16. 16.
    DuPree CE, Blair K, Steele SR, et al. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg. 2014;149(4):328–34.CrossRefGoogle Scholar
  17. 17.
    Inaba CS, Koh CY, Sujatha-Bhaskar S, et al. One-year mortality after contemporary laparoscopic bariatric surgery: an analysis of the bariatric outcomes longitudinal database. J Am Coll Surg. 2018;226(6):1166–74.CrossRefGoogle Scholar
  18. 18.
    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):410–22.CrossRefGoogle Scholar
  19. 19.
    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.CrossRefGoogle Scholar
  20. 20.
    Khoursheed M, Al-Bader I, Mouzannar A, et al. Postoperative bleeding and leakage after sleeve gastrectomy: a single-center experience. Obes Surg. 2016;26(12):2944–51.CrossRefGoogle Scholar
  21. 21.
    Wang Z, Dai X, Xie H, et al. The efficacy of staple line reinforcement during laparoscopic sleeve gastrectomy: a meta-analysis of randomized controlled trials. Int J Surg. 2016;25:145–52.CrossRefGoogle Scholar
  22. 22.
    Nielsen AW, Helm MC, Kindel T, et al. Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery. Surg Endosc. 2018;32(5):2488–95.CrossRefGoogle Scholar
  23. 23.
    Dick A, Byrne TK, Baker M, et al. Gastrointestinal bleeding after gastric bypass surgery: nuisance or catastrophe? Surg Obes Relat Dis. 2010;6(6):643–7.CrossRefGoogle Scholar
  24. 24.
    Shikora SA, Mahoney CBJO. Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25(7):1133–41.CrossRefGoogle Scholar
  25. 25.
    Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic bariatric surgery. Ann Gastroenterol. 2018;31(1):56–64.Google Scholar
  26. 26.
    Rached AA, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol. 2014;20(38):13904–10.CrossRefGoogle Scholar
  27. 27.
    Warner DL, Sasse KC. Technical details of laparoscopic sleeve gastrectomy leading to lowered leak rate: discussion of 1070 consecutive cases. Minim Invasive Surg. 2017;2017Google Scholar
  28. 28.
    Khuri SF, Henderson WG, Daley J, et al. The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg. 2007;204(6):1089–102.CrossRefGoogle Scholar
  29. 29.
    Cohen ME, Ko CY, Bilimoria KY, et al. Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg. 2013;217(2):336–46. e331CrossRefGoogle Scholar
  30. 30.
    Ingraham AM, Richards KE, Hall BL, et al. Quality improvement in surgery: the American College of Surgeons national surgical quality improvement program approach. Adv Surg. 2010;44(1):251–67.CrossRefGoogle Scholar
  31. 31.
    Chang SH, Stoll CR, Song J, et al. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–87.CrossRefGoogle Scholar
  32. 32.
    Varban OA, Sheetz KH, Cassidy RB, et al. Evaluating the effect of operative technique on leak rates after laparascopic sleeve gastrectomy: a case control study. Surg Obes Relat Dis. 2017;13:560–7.CrossRefGoogle Scholar
  33. 33.
    Angrisani L, Cutolo PP, Buchwald JN, et al. Laparoscopic reinforced sleeve gastrectomy: early results and complications. Obes Surg. 2011;21(6):783–93.CrossRefGoogle Scholar
  34. 34.
    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.CrossRefGoogle Scholar
  35. 35.
    Gagner M. Decreased incidence of leaks after sleeve gastrectomy and improved treatments. Surg Obes Relat Dis. 2014;10(4):611–2.CrossRefGoogle Scholar
  36. 36.
    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.CrossRefGoogle Scholar
  37. 37.
    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.CrossRefGoogle Scholar
  38. 38.
    Jurowich C, Thalheimer A, Seyfried F, et al. Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Langenbeck's Arch Surg. 2011;396:981–7.CrossRefGoogle Scholar
  39. 39.
    Yuval JB, Mintz Y, Cohen MJ, et al. The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size. Obes Surg. 2013;23(10):1685–91.CrossRefGoogle Scholar
  40. 40.
    Musella M, Milone M, Maietta P, et al. Laparoscopic sleeve gastrectomy: efficacy of fibrin sealant in reducing postoperative bleeding. A randomized controlled trial. Updat Surg. 2014;66(3):197–201.CrossRefGoogle Scholar
  41. 41.
    D’Ugo S, Gentileschi P, Benavoli D, et al. Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: a multicenter study. Surg Obes Relat Dis. 2014;10(3):450–4.CrossRefGoogle Scholar
  42. 42.
    Iossa A, Abdelgawad M, Watkins MB, et al. Leaks after laparoscopic sleeve gastrectomy: an over of pathogenesis and risk factors. Langenbeck's Arch Surg. 2016;401(6):757–66.CrossRefGoogle Scholar
  43. 43.
    Reza FA, Li S, Inaba C, et al. Risk factors for gastrointestinal leak after bariatric surgery: MBSAQIP analysis. J Am Coll Surg. 2018;227(1):135–41.CrossRefGoogle Scholar
  44. 44.
    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;23:2013–7.CrossRefGoogle Scholar
  45. 45.
    Janik MR, Walędziak M, Brągoszewski J, et al. Prediction model for hemorrhagic complications after laparoscopic sleeve gastrectomy: development of SLEEVE BLEED calculator. Obes Surg. 2017;27:968–72.CrossRefGoogle Scholar
  46. 46.
    de Angelis F, Abdelgawad M, Rizzello M, et al. Perioperative hemorrhagic complications after laparoscopic sleeve gastrectomy: four-year experience of a bariatric center of excellence. Surg Endosc. 2017;31:3547–51.CrossRefGoogle Scholar
  47. 47.
    Noel P, Nedelcu M, Gagner M. Impact of the surgical experience on leak rate after laparoscopic sleeve gastrectomy. Obes Surg. 2016;26:1782–7.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Surgery, Division of Minimally Invasive and Bariatric SurgeryTemple University HospitalPhiladelphiaUSA
  2. 2.Division of BiostatisticsLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
  3. 3.Department of Surgery, Division of General SurgeryMayo ClinicJacksonvilleUSA

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