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Staple line leaks and bleeds

Understanding intraoperative staple line leaks and bleeds

The etiology of intraoperative leaks is unknown and highly likely to be multifactorial, depending on patient factors, surgical technique, and device malfunction

According to a non-systematic review of the current literature intraoperative staple line leaks and bleeds are primarily associated with stapler misfires following laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The paper, ‘A Narrative of Intraoperative Staple Line Leaks and Bleeds During Bariatric Surgery’, authored by Sudip K Ghosh, Sanjoy Roy, Ed Chekan and Elliott J Fegelman (all from Ethicon Inc.), states that although the incidence of intraoperative staple line leaks and bleeds “appears to be relatively low, it may be underestimated as a result of underreporting, the precautionary use of SLR, lack of standardized testing, and the capacity of some leaks and bleeds to resolve with little or no treatment.”

Published in Obesity Surgery, the paper claims that staple line failure with gastric leak is one of the most serious and feared complications from both LSG and LRYGB, with a post-operative leak rate for LSG between 1-3% and a leak rate for LRYGB 0.1-5.6%. Therefore, the authors decided to examine the incidence of intraoperative staple line leaks and bleeds for LSG and LRYGB. Relevant studies were further evaluated for the use of intraoperative leak testing and staple line interventions, as well as the potential impact on complications and clinical efficiency factors.

The researchers conducted a medical literature and identified 16 publications describing intraoperative bleeds, leaks, and interventions at the staple line for LSG and LRYGB. The databases MEDLINE®, EMBASE™, and Biosis were restricted to a search period from January 2010 to June 2015. Titles were searched using the key words laparoscopic sleeve gastrectomy or sleeve gastrectomy or gastric bypass. The results were filtered using a key word search of the full citation, abstract, and descriptor for staple line or laparoscopic or leak or bleed and intraoperative or intervention, with appropriate truncations. Case reports were excluded.In all the papers, intraoperative leaks were identified “based on a positive intraoperative leak test, whereas intraoperative bleeds were identified based on surgeon examination of the staple line that may or may not require adjunct staple line interventions.”

The authors stated that it “is somewhat remarkable with regard to how infrequently and incompletely these events (intraoperative leaks and bleeds) are currently documented and reported”, after LSG and LRYGB.

They add that of the 12 LSG articles included, intraoperative leaks were reported in three studies, and bleeds were reported in four studies, with an incidence of up to 3.93 and 4.07 %, respectively. For LRYGB, two of four articles reported leaks and/or bleeds in up to 8.26 and 3.45 % of cases, respectively.

“The etiology of intraoperative leaks is unknown and highly likely to be multifactorial, depending on patient factors, surgical technique, and device malfunction,” they write. “Stapler misfires were cited as the cause of device-related staple line failures, while other studies implicated the inherent characteristics of the tissue at specific locations (such as the GEJ for LSG and the GJ site for LRYGB) as well as the experience of the surgeon.”

“In the intraoperative setting, there is insufficient data to assess the economic impact of leaks and bleeds and whether the added cost of SLR can be justified by improvements in clinical efficiency or outcomes,” they conclude. “Ultimately, development of new stapler designs that improve staple line integrity may obviate the need for SLR, increase efficiency, and lead to better outcomes for patients undergoing bariatric surgery.”

The article was edited from the original article, under the Creative Commons license. To access the article, please click here

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