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Preventing complications from sleeve gastrectomy

Preventing staple line leaks - tranexemic acid, thickness calibration device and none layer of buttressing material

A series of presentations at the XIX IFSO World Congress in Montreal, Canada, examined some of the common complications that occur following sleeve gastrectomy and what can be done to prevent their occurrence.

Mr Saurav Chakravartty and colleagues from King’s College Hospital (London, UK) evaluated whether intra-operative tranexemic acid can be used to reduce staple line bleeding.

Saurav Chakravartty

“Staple line bleeding is a common intra-operative complication although opinion is divided on the best measure to deal it – is it expensive reinforcement strategies, suturing the staple line or diathermy?,” said Chakravartty. “Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery.”

In the study consecutive patients undergoing LSG by one surgeon were chosen as controls while those operated by the second surgeon were assigned to have tranexemic acid (1g) injection on induction. Uniform anaesthetic, thromboprophylaxis protocols and operative techniques with identical staplers without reinforcement were adopted in all patients. They compared the number of staple line bleeding points requiring the placement of a haemostatic stitch in either group.

A total of 25 patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 42 years), BMI (median 54.7 vs 52 kg/m2), gender distribution (female: male=19:6 vs 20:5) and co-morbidities.

They reported that the treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (2 vs 0, p<0.05), incurred lower intraoperative blood loss (p<0.01) and had quicker operating times (median 84 vs 66 minutes, p<0.05). Morbidity was similar in both groups.

“Intra-operative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times,” he concluded.

Thickness calibration device

In her presentation, Dr Rose Huang (Boehringer Laboratories) suggested that  leaks after sleeve gastrectomy may be due to a mismatch between staple height and tissue thickness.

She and colleagues designed a study to assess the range of gastric thicknesses in three areas of stapling. The performed sleeve gastrectomy using a suction calibration system of 40Fr; and 4cm from the pylorus. Measurement of combined gastric walls was performed with an applied pressure of 8g/mm2 on the fundus, mid-body and antrum areas.

Rose Huang

A total of 26 patients were enrolled (15 women), the mean age was 36.8 years and mean BMI for male patients was 44.7 and 45.7 for female patients. Although male patients had a thicker antrum than female patients (3.12 mm vs. 3.09 mm), the mid-body of the stomach (2.57 mm vs. 3.09 mm) and proximal areas (1.67 mm vs. 1.72mm) were thicker in female patients.

She noted that the range varied with a maximum thicknesses of up to 2.83 mm in female fundi and 2.28 mm in male patients. Some antra were as thick as 4.07 mm in females and 5.39 in males. Also, men had a longer average staple line (22.95 cm vs. 19.90 cm).

“Due to the range of gastric thicknesses, one mean staple height cannot satisfactorily appose the full range of gastric walls thicknesses without potentially causing necrosis or poor apposition,” she concluded. “To help avoid leaks, a thickness calibration device is needed to correctly decide staple height.”

One layer of buttressing material

According to Dr Hector Alfredo Conoman from Santiago, Chile, reducing the incidence of gastric leak and haemorrhage can be achieved by reinforcing the  staple line with a buttressing material and reported his centre’s experience in relation to bleeding, leaks, mortality and operative time.

A prospective case series of 703 patients (572 female) who went to sleeve gastrectomy with one layer of buttressing material between December 2009 to June 2013 and who were followed with a specific protocol.

The mean preoperative weight was 98.3±15kg, mean preoperative BMI37 ±3.1 and mean excess weight was 31.6±12.3kg.

Hector Alfredo Conoman

He reported that the mean procedure time was 58.7±20.2 (35 to 150) minutes and at six months the mean percentage excess BMI loss was 70.1 ± 24.2 (range 26.1 to 134.4).

A total of 20 patients (2.8%) reported complications four instances of bleeding, two which required reoperation. There were no deaths or instances of leaks.

“The use of one layer buttressing material is effective, safety and may reduce the episodes of haemorrhage and leaks in similar way than using the two layers on stapler line,” he concluded. “This may avoid misfiring because the thickness in some patients, as well as reduce costs.”

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