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Delivering consistent outcomes in sleeve gastrectomy
At the recent European Obesity Summit in Gothenburg, Sweden, Medtronic hosted a symposium, which included presentations on how to improve outcomes from a sleeve gastrectomy and anaesthetic issues in bariatric surgery.
Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure even in high risk patients - and surgeons have excellent tools now to help perform the surgery safely and consistently. However, the procedure should not be considered an easy operation to perform, according to Mr Ahmed R Ahmed, Consultant Surgeon, St Mary’s Hospital, Imperial College NHS Trust, UK.
In his presentation, ‘Personal experience with delivering consistent outcomes in sleeve gastrectomy’, he began by stating that sleeve gastrectomy has increased in popularity primarily as it is a less complex procedure for surgeons and therefore avoids the operative and post-operative complications associated with LRYGB, and does not involve the multiple post-operative adjustments of LAGB.
Mr Ahmed said that over the years, several technical and technological innovations have helped him to improve his operative sleeve technique and therefore, his outcomes. For example, to maximise the best outcomes when resecting the stomach he starts no less 3cm from the pylorus. The exact location does depend on the individual anatomy of the patient nevertheless, he explained this measurement is important as it can influence post-operative regurgitation. Mr Ahmed also closes all hiatal dimples/defects as both the anatomical (hiatal hernia) and the physiological (lower oesophageal sphincter) play important, but independent, roles in post-operative reflux.
With regards to technological innovations, he now employs the i-Drive with TriStaple technology (Medtronic) as it eliminates the manual firing force and improves manoeuvrability. He added that the Ligasure Maryland (Medtronic) allows for more efficient transection speed with one-step sealing, dividing and reduced instrument exchanges. Mr Ahmed also discussed the Gastrisail gastric positioning system (Medtronic), a 3-in-1 device he said facilitates suction, decompression and sizing when performing a sleeve gastrectomy.
However, despite these advances and innovations, there are still several concerns he has about the procedure and he offered some valuable insights as to how such complications can be avoided. His primary concerns were:
- Staple line disruption (in revision procedures)
- Bleeding from the staple line
- Bougie bleeding
- Bleeding from the gastric or short gastric vessels
- Bleeding from the spleen; and
- Exposure difficulty in super-super obese patients
To overcome these issues he said that it was important to remember that ‘the staple line was king’ and is of paramount importance to the success of the procedure. Therefore, it is crucial that tissue thickness measurements are taken at the Antrum, Midbody and Fundus, again taking into account the individual anatomical measurements of the patient. To maximise the impact of staple line closure, the choice/size of staple is again crucial, as the dimensions of the closed staples do differ from blue (standard) to green (standard), 1.50-2.0mm, respectively.
He said that there is some controversy regarding where to start the sleeve and whether the antrum should be spared or not. However, a randomised study by Abdallah E et al (Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study. Obesity Surgery. 2014 Oct;24(10):1587-94), had shown that increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.
A second controversy is concerned with bougie size and whether a smaller calibre 32-44Fr results in better weight loss or it is unsafe. A study by Yuval et al (The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size? Obesity Surgery. 2013 Oct;23(10):1685-91), that assessed bougie size for LSG found the use of bougie size 40 French (F) and larger was associated with a leak rate of 0.92% as opposed to 2.67% for smaller bougies (p<0.05).
In addition, they reported that weight loss as a percentage of extra weight loss (%EWL) was 69.2% when a bougie 40F and larger was used, as opposed to 60.7% of EWL when smaller bougies were used (p=0.29). They recommended surgeons should avoid using the smallest bougie possible because the risks may outweigh the benefits.
Finally, Mr Ahmed discussed the importance of staple line reinforcement and whether it does result in reducing the risk of bleeding/leakage at the staple line. A paper by Baker et al (The science of stapling and leaks. Obesity Surgery. 2004 Nov-Dec;14(10):1290-8) reviewing the history of stapling and discussing the implications of understanding the biomechanics of stapling living tissue, evaluated ways to optimise staple-line strength. This paper reported that staple line reinforcement significantly increased the mean leak pressure, compared to no staple line reinforcement (p=0.019)
Moreover, in a comparison of no reinforcement, oversewing, non-absorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM), Gagner and Buchwald (Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. SOARD. 2014 Jul-Aug;10(4):713-23), reported that leak rates ranged from 1.09% (APM) to 3.3% (BPS). However, APM leak rate was significantly lower than other groups (p<0.05).
Mr Ahmed concluded that surgeons should use all the technological innovations at their disposal and adhere to the guidelines when performing LSG in order to achieve safe and long-and effective term outcomes for patients.
To read the article, 'Anaesthetic issues in bariatric surgery', please click here