OBES SURG DOI 10.1007/s11695-014-1439-z
LETTER TO THE EDITOR
Division of the Stomach and Checking Haemostasis for Performing Sleeve Gastrectomy. Points of Controversy Radwan Kassir & Pierre Blanc & Imed Ben Amor & Patrice Lointier & Tarek Debs & Antonio Iannelli & Jean Gugenheim
# Springer Science+Business Media New York 2014
Introduction Sleeve gastrectomy is not as straightforward as one might think and requires meticulous dissection and a number of operation principles [1]. There are many technical controversies which explain why there is no standardised technique in 2014 and the difficulty in interpreting published results. We discuss the controversial subject of the division of the stomach and checking haemostasis.
Points of Controversy Teams vary as to their choice of type of gastroplasty tube: either the ring, the MIDSLEEVE (MID, Medical Innovation Development, France) developed for this type of surgery, or a reusable Faucher tube. Although the volume of the 25-cm tube is the same as a 32 or 40Fr bougie, a narrower tube achieves better weight loss [2]. For this reason, the 2011 consensus conference agreed on the use of a tube of between 32 and 36Fr diameter. Another point of controversy is the thickness of the staples. The consensus conference R. Kassir (*) Department of Bariatric Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France e-mail: [email protected] P. Blanc Department of Digestive Surgery, Clinique Chirurgicale Mutualiste de Saint-Etienne, Saint Etienne, France I. B. Amor : T. Debs : A. Iannelli : J. Gugenheim Department of Bariatric Surgery, Archet 2 Hospital, University Hospital of Nice, Nice, France P. Lointier Department of Digestive Surgery, Clinique de la Châtaigneraie, Beaumont, France
recommended staples over 2.5 mm deep for first line surgery and staples of at least 4.8 mm deep for revision surgery (when the tissues are thicker). It is recognised that the wall of the antrum is thicker than that of the rest of the stomach and increases in thickness with increasing BMI [3]. Despite this, teams vary greatly as to the type of staples they use: 4.8 (green) for the antrum then 3.5 (blue) for the rest of the stomach, or conversely 3.5 for the antrum and 4.8 for the stomach, or 3.8 mm (gold) for the entire stomach or 3.5 (blue) for all the stapling, or alternatively violet charges (33.5-4) for the whole stomach [4]. There are no comparative studies between the type of clamp and the staple charge used, nor are there any comparative studies about preoperative event rates (stapling failure) or postoperative complications (fistulae or bleeding). Some surgeons routinely add a ligature around the stapling line overlap. Another point of debate is how to perform the stapling: either very tightly onto the tube or simply in contact without applying tension to the tissue (causing less ischaemia?). Finally, the question of possibly reinforcing the stapling to reduce the risk of fistulae remains open. The incidence of fistulae is between 0 and 5 % for initial surgery and doubles for revision surgery [5]. No studies have yet provided a conclusion on the impact of reinforcement on fistulae rates. As the incidence of fistulae is low, a series of over 10,000 procedures would be needed in order to obtain statistically valid data [6]. Different options have been proposed to try to reduce the risk of fistulae, including sutures, biological glues and strengthening the stapling. Although glues have not been proved to be effective, a few studies have described reduced fistulae rates [7]. When the stapling line is oversewn, the technique used also varies between groups: the oversewing may either roll over the stapling line, although in this case, a wider tube is needed to have sufficient gastric tissue (“plicatured sleeve”!) or the oversewing follows the stapling line (a procedure causing ischaemia?) [8]. In addition, the size and type of needle and suture material used also varies
OBES SURG
between different teams: triangular or round needles and resorbable or non-resorbable sutures (believed to reduce dilatation?). Securing the greater omentum onto the stapling line in order to fix the gastric tube has also been described and is reported to reduce the risk of torsion of the gastric tube [8]. Stapling reinforcers such as SEAMGUARD® (Gore, Flagstaff, AZ) significantly reduce bleeding from the stapling line [9]. This is a tissue (67 % synthetic polyglycolic acid, 33 % trimethylene carbonate) which resorbs over 23 weeks. The effects of these reinforcers on the risk of fistulae are still debated [9]. The stapling/division end must not come into contact with the oesophagus. A 1 to 2-cm safety margin would appear to be reasonable, although this does not completely abolish the risk of fistulae formation [4]. The division area may also impact on the tone of the inferior oesophageal sphincter (tone is greater if the division is carried out close to the oesophagus) (influence on possible gastro-oesophageal reflux?) [10].
Conflict of Interest The authors (Radwan Kassir, Pierre Blanc, Antonio Iannelli, Patrice Lointier, Tarek Debs, Imed Ben Amor, Jean Gugenheim) have no conflicts of interests to declare in relation to this article. Statement of Informed Consent “Informed consent was obtained from all individual participants included in the study.” Statement of Human and Animal Rights “Informed consent was obtained from all individual participants included in the study.”
References 1. Kassir R, Breton C, Lointier P, Blanc P. Laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunostomy using an absorbable bidirectional monofilament barbed suture: review of the literature and illustrative case video. Surg Obes Relat Dis. 2014;10:560–1. 2. Deitel M, Gagner M, Erickson AL, et al. Third international summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: 749–59. 3. Kunisaki C, Makino H, Takagawa R, et al. Prospective randomized controlled trial comparing the use of 3.5-mm and 4.8-mm staples in gastric surgery. Hepatogastroenterology. 2008;55:1943–7. 4. Gadiot RPM, Biter LU, Zengerink HJF, et al. Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results. Obes Surg. 2012;22:320–9. 5. Rebibo L, Fuks D, Blot C, et al. Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc. 2013;27:2849–55. 6. Chen B, Kiriakopoulos A, Tsakayannis D, et al. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg. 2009;19:166–72. 7. Silecchia G, Boru CE, Mouiel J, et al. Clinical evaluation of fibrin glue in the prevention of anastomotic leak and internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial. Obes Surg. 2006;16:125–31. 8. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–8. 9. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20: 462–7. 10. Petersen WV, Meile T, Küper MA, et al. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg. 2012;22:360–6.
LETTER TO THE EDITOR
Division of the Stomach and Checking Haemostasis for Performing Sleeve Gastrectomy. Points of Controversy Radwan Kassir & Pierre Blanc & Imed Ben Amor & Patrice Lointier & Tarek Debs & Antonio Iannelli & Jean Gugenheim
# Springer Science+Business Media New York 2014
Introduction Sleeve gastrectomy is not as straightforward as one might think and requires meticulous dissection and a number of operation principles [1]. There are many technical controversies which explain why there is no standardised technique in 2014 and the difficulty in interpreting published results. We discuss the controversial subject of the division of the stomach and checking haemostasis.
Points of Controversy Teams vary as to their choice of type of gastroplasty tube: either the ring, the MIDSLEEVE (MID, Medical Innovation Development, France) developed for this type of surgery, or a reusable Faucher tube. Although the volume of the 25-cm tube is the same as a 32 or 40Fr bougie, a narrower tube achieves better weight loss [2]. For this reason, the 2011 consensus conference agreed on the use of a tube of between 32 and 36Fr diameter. Another point of controversy is the thickness of the staples. The consensus conference R. Kassir (*) Department of Bariatric Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France e-mail: [email protected] P. Blanc Department of Digestive Surgery, Clinique Chirurgicale Mutualiste de Saint-Etienne, Saint Etienne, France I. B. Amor : T. Debs : A. Iannelli : J. Gugenheim Department of Bariatric Surgery, Archet 2 Hospital, University Hospital of Nice, Nice, France P. Lointier Department of Digestive Surgery, Clinique de la Châtaigneraie, Beaumont, France
recommended staples over 2.5 mm deep for first line surgery and staples of at least 4.8 mm deep for revision surgery (when the tissues are thicker). It is recognised that the wall of the antrum is thicker than that of the rest of the stomach and increases in thickness with increasing BMI [3]. Despite this, teams vary greatly as to the type of staples they use: 4.8 (green) for the antrum then 3.5 (blue) for the rest of the stomach, or conversely 3.5 for the antrum and 4.8 for the stomach, or 3.8 mm (gold) for the entire stomach or 3.5 (blue) for all the stapling, or alternatively violet charges (33.5-4) for the whole stomach [4]. There are no comparative studies between the type of clamp and the staple charge used, nor are there any comparative studies about preoperative event rates (stapling failure) or postoperative complications (fistulae or bleeding). Some surgeons routinely add a ligature around the stapling line overlap. Another point of debate is how to perform the stapling: either very tightly onto the tube or simply in contact without applying tension to the tissue (causing less ischaemia?). Finally, the question of possibly reinforcing the stapling to reduce the risk of fistulae remains open. The incidence of fistulae is between 0 and 5 % for initial surgery and doubles for revision surgery [5]. No studies have yet provided a conclusion on the impact of reinforcement on fistulae rates. As the incidence of fistulae is low, a series of over 10,000 procedures would be needed in order to obtain statistically valid data [6]. Different options have been proposed to try to reduce the risk of fistulae, including sutures, biological glues and strengthening the stapling. Although glues have not been proved to be effective, a few studies have described reduced fistulae rates [7]. When the stapling line is oversewn, the technique used also varies between groups: the oversewing may either roll over the stapling line, although in this case, a wider tube is needed to have sufficient gastric tissue (“plicatured sleeve”!) or the oversewing follows the stapling line (a procedure causing ischaemia?) [8]. In addition, the size and type of needle and suture material used also varies
OBES SURG
between different teams: triangular or round needles and resorbable or non-resorbable sutures (believed to reduce dilatation?). Securing the greater omentum onto the stapling line in order to fix the gastric tube has also been described and is reported to reduce the risk of torsion of the gastric tube [8]. Stapling reinforcers such as SEAMGUARD® (Gore, Flagstaff, AZ) significantly reduce bleeding from the stapling line [9]. This is a tissue (67 % synthetic polyglycolic acid, 33 % trimethylene carbonate) which resorbs over 23 weeks. The effects of these reinforcers on the risk of fistulae are still debated [9]. The stapling/division end must not come into contact with the oesophagus. A 1 to 2-cm safety margin would appear to be reasonable, although this does not completely abolish the risk of fistulae formation [4]. The division area may also impact on the tone of the inferior oesophageal sphincter (tone is greater if the division is carried out close to the oesophagus) (influence on possible gastro-oesophageal reflux?) [10].
Conflict of Interest The authors (Radwan Kassir, Pierre Blanc, Antonio Iannelli, Patrice Lointier, Tarek Debs, Imed Ben Amor, Jean Gugenheim) have no conflicts of interests to declare in relation to this article. Statement of Informed Consent “Informed consent was obtained from all individual participants included in the study.” Statement of Human and Animal Rights “Informed consent was obtained from all individual participants included in the study.”
References 1. Kassir R, Breton C, Lointier P, Blanc P. Laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunostomy using an absorbable bidirectional monofilament barbed suture: review of the literature and illustrative case video. Surg Obes Relat Dis. 2014;10:560–1. 2. Deitel M, Gagner M, Erickson AL, et al. Third international summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: 749–59. 3. Kunisaki C, Makino H, Takagawa R, et al. Prospective randomized controlled trial comparing the use of 3.5-mm and 4.8-mm staples in gastric surgery. Hepatogastroenterology. 2008;55:1943–7. 4. Gadiot RPM, Biter LU, Zengerink HJF, et al. Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results. Obes Surg. 2012;22:320–9. 5. Rebibo L, Fuks D, Blot C, et al. Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc. 2013;27:2849–55. 6. Chen B, Kiriakopoulos A, Tsakayannis D, et al. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg. 2009;19:166–72. 7. Silecchia G, Boru CE, Mouiel J, et al. Clinical evaluation of fibrin glue in the prevention of anastomotic leak and internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial. Obes Surg. 2006;16:125–31. 8. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–8. 9. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20: 462–7. 10. Petersen WV, Meile T, Küper MA, et al. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg. 2012;22:360–6.
