Surgical Strategies That May Decrease Leak After Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis of 9991 Cases
TL;DR: In this paper, a systematic review was conducted to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG) procedures, which is growing in popularity as a primary bariatric procedure.
Abstract: Objective:To conduct a systematic review to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG).Background:LSG is growing in popularity as a primary bariatric procedure. Technical aspects of LSG including bougie size remain controversial.Methods:Our system
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TL;DR: LSG was relatively safe, and further long-term surveillance is necessary.
Abstract: LSG has been increasingly performed. Long-term follow-up is necessary. During the Fourth International Consensus Summit on LSG in New York Dec. 2012, an online questionnaire (SurveyMonkey®) was filled out by 130 surgeons experienced in LSG. The survey was submitted directly to the statisticians. The 130 surgeons performed 354.9 ± SD 453 LSGs/surgeon (median 175), for a total of 46,133 LSGs. The LSGs had been performed over 4.9 ± 2.7 year (range 1–10). Of the 46,133 LSGs, 0.2 ± 1.0 % (median 0, range 0–10 %) were converted to an open operation. LSG was intended as the sole operation in 93.1 ± 14.8 %; in 3.0 ± 6.3 %, a second stage became necessary. Of the 130 surgeons, 40 (32 %) use a 36F bougie, which was most common (range 32–50F). Staple-line is reinforced by 79 %; of these, 57 % use a buttress and 43 % over-sew. Mean %EWL at year 1 was 59.3 %; year 2, 59.0 %; year 3, 54.7 %; year 4, 52.3 %; year 5, 52.4 %; and year 6, 50.6 %. If a second-stage operation becomes necessary, preference was: RYGB 46 %, duodenal switch 24 %, re-sleeve 20 %, single-anastomosis duodenoileal bypass 3 %, sleeve plication 3 %, minigastric bypass 3 %, non-adjustable band 2 %, and side-to-side jejunoileal anastomosis 1 %. Complications were: high leak 1.1 %, hemorrhage 1.8 %, and stenosis at lower sleeve 0.9 %. Postoperative gastroesophageal reflux occurred in 7.9 ± 8.2 % but was variable (0–30 %). Mortality was 0.33 ± 1.6 %, which translates to ∼152 deaths. Eighty-nine percent order multivitamins (including vitamin D, calcium, and iron) and 72 % order B12. A PPI is ordered by 29 % for 1 month, 29 % for 3 months, and others for 1–12 months depending on the case. LSG was relatively safe. Further long-term surveillance is necessary.
304 citations
Cites background or methods from "Surgical Strategies That May Decrea..."
...Furthermore, narrower bougies have been found to result in a higher incidence of gastric leaks [37, 38]....
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...However, using a ≥40F bougie has not decreased %EWL thus far up to 36 months [37]....
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TL;DR: There is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity and health care regulators should introduce appropriate reimbursement policies.
Abstract: Despite growing evidence that bariatric/metabolic surgery powerfully improves type 2 diabetes (T2D), existing diabetes treatment algorithms do not include surgical options. The 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, was convened in collaboration with leading diabetes organizations to develop global guidelines to inform clinicians and policymakers about benefits and limitations of metabolic surgery for T2D. A multidisciplinary group of 48 international clinicians/scholars (75% nonsurgeons), including representatives of leading diabetes organizations, participated in DSS-II. After evidence appraisal (MEDLINE [1 January 2005–30 September 2015]), three rounds of Delphi-like questionnaires were used to measure consensus for 32 data-based conclusions. These drafts were presented at the combined DSS-II and 3rd World Congress on Interventional Therapies for Type 2 Diabetes (London, U.K., 28–30 September 2015), where they were open to public comment by other professionals and amended face-to-face by the Expert Committee. Given its role in metabolic regulation, the gastrointestinal tract constitutes a meaningful target to manage T2D. Numerous randomized clinical trials, albeit mostly short/midterm, demonstrate that metabolic surgery achieves excellent glycemic control and reduces cardiovascular risk factors. On the basis of such evidence, metabolic surgery should be recommended to treat T2D in patients with class III obesity (BMI ≥40 kg/m2) and in those with class II obesity (BMI 35.0–39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy. Surgery should also be considered for patients with T2D and BMI 30.0–34.9 kg/m2 if hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications. These BMI thresholds should be reduced by 2.5 kg/m2 for Asian patients. Although additional studies are needed to further demonstrate long-term benefits, there is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity. To date, the DSS-II guidelines have been formally endorsed by 45 worldwide medical and scientific societies. Health care regulators should introduce appropriate reimbursement policies.
259 citations
Cites background from "Surgical Strategies That May Decrea..."
...concernant l’impact de la calibration dans la survenue de la fistule post‐sleeve [8]....
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TL;DR: In this paper, the authors compared laparoscopic sleeve gastrectomy (LSG) staple-line leak rates of four prevalent surgical options: no reinforcement, oversewing, nonabsorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM).
217 citations
TL;DR: Kim et al. as discussed by the authors presented the ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management.
164 citations
TL;DR: LSG is a safe procedure with a low morbidity rate but SLR is associated with increased leak rates and a surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.
Abstract: Questions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year.
Using the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level.
A total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00–1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63–0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62–0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80–0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP.
LSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.
162 citations
Cites background or result from "Surgical Strategies That May Decrea..."
...Two recently published systematic reviews revealed a lower leak rate with BS 40 Fr.(10,13) Other studies have identified no difference in leak rates between BSs, concluding that the difference in intraluminal pressures is not clinically relevant....
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...DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP. Conclusion: LSG is a safe procedure with a low morbidity rate....
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...The International Sleeve Gastrectomy Expert Panel Consensus Statement suggests an optimal BS between 32 and 36 Fr because of increases complications with a BS <32 and lack of long-term restriction with BS >36 Fr.48 Conversely, other studies have demonstrated that BS has no significant association with weight loss.49 Our study suggests that a larger BS 38 Fr is associated with an increased excess weight loss, similar to the study by Aurora et al10 wer Health, Inc....
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...Our findings were not consistent with other studies that conclude there is no difference in weight loss based on the DP.(13) Our data suggest that as DP increased, there was an increased excess weight loss, possibly explained by preserving the ‘‘antral mill....
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...Some surgeons believe that starting gastric resection >5 cm from the pylorus may decrease the risk of kinking at the incisura, decreasing intraluminal pressure, and potentially decrease leak rate; however, our data do not support this conclusion.52 A study investigated comorbidity resolution in antral-preserving LSG versus antral-resection LSG and found no significant differences between the groups, supporting our findings of no associations between comorbidity resolution and DP.15 Our data show significantly increased excess weight loss in a stepwise fashion as the DP increases....
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References
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TL;DR: An Explanation and Elaboration of the PRISMA Statement is presented and updated guidelines for the reporting of systematic reviews and meta-analyses are presented.
Abstract: Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.
Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.
The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
25,711 citations
TL;DR: This is the first prospective, multiinstitutional, nationwide, clinically rich, bariatric-specific data comparing sleeve gastrectomy to the adjustable gastric band, and the gastric bypass and LSG has morbidity and effectiveness positioned between the LAGB and the LRYGB/ORYGB for data up to 1 year.
Abstract: Objective:To assess the safety and effectiveness of the laparoscopic sleeve gastrectomy (LSG) as compared to the laparoscopic adjustable gastric band (LAGB), the laparoscopic Roux-en-Y gastric bypass (LRYGB) and the open Roux-en-Y gastric bypass (ORYGB) for the treatment of obesity and obesity-relat
624 citations
TL;DR: Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge, and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak.
Abstract: Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation. An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were “sleeve gastrectomy” OR “gastric sleeve” AND “leak.” We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation. The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m2] and 2.2% for BMI < 50 kg/m2. Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful. Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m2) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge.
543 citations
TL;DR: The present systematic review was to evaluate the evidence regarding weight loss, complication rates, ostoperative mortality, and co-morbidity improvement afer SG.
504 citations
TL;DR: Early results may show that Seamguard® reduces staple-line hemorrhage and leakage, which may have contributed to shorter hospital stay, decreased costs and lower morbidity after laparoscopic bariatric surgery.
Abstract: Background: Laparoscopically performed sleeve gastrectomy may be employed as an adjunct to biliopancreatic diversion with duodenal switch (BPD-DS), to induce early satiety and weight loss in morbidly obese patients. Complications from this gastric procedure include staple-line leakage or hemorrhage. The efficacy of a staple-line buttressing material, an absorbable polymer membrane (Seamguard®, Gore), in reducing these complications, was investigated. Methods: A prospective consecutive series of 20 patients who underwent a laparoscopic sleeve gastrectomy in conjunction with BPD-DS were studied. In 10 patients, the absorbable polymer membrane was integrated into the gastric linear staple-line (group A). In a control group of 10 patients, a conventional linear stapling system was used (group B). The following data were recorded: demographics, intraoperative blood loss, staple-line leakage and hospital stay. Results: Demographic profile was similar in both groups. Operative data, including type, duration and strategy of operation as well as surgeon's experience were well matched. Peroperative blood loss (120 ml vs 210 ml) was significantly higher in group B (P <0.05). Median length of hospital stay was 3.8 days (range 2-8 days) in group A and 4.6 days (range 4-12 days) in group B. There was no mortality. Morbidity was encountered in 3 patients (all group B), including 2 staple-line hemorrhages (10%) and 1 subphrenic abscess (5%). Conclusion: These early results may show that Seamguard® reduces staple-line hemorrhage and leakage. This may have contributed to shorter hospital stay, decreased costs and lower morbidity after laparoscopic bariatric surgery.
228 citations