The Covidien TriStaple System vs. the Duet Tissue Buttress in Laparoscopic Sleeve Gastrectomy: a Comparative Study

Mark A Dykstra, Noah J Switzer, Caroline E Sheppard, Kevin A Whitlock, Richdeep S Gill, Xinzhe Shi, Daniel Birch, Shahzeer Karmali. Department of Surgery, University of Alberta, Edmonton, Alberta; Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta..

Background and Objectives
The laparoscopic sleeve gastrectomy (LSG) is growing increasingly popular as a first line bariatric procedure due to its ability to both restrict oral intake and modulate gut hormone regulation. The most significant challenge for surgeons associated with LSG is postoperative hemorrhage and gastric staple line leakage. To mitigate the risk of these complications, bariatric surgeons have promoted numerous preventative techniques. These techniques include over-sewing the staple line, adding buttress material and, most recently, adding additional staples lines. Our objective was to assess and compare two of these techniques: staple line reinforcement via the Duet tissue buttress reinforcement stapler system and the Covidien TriStaple design. We performed a qualitative institutional review of complications in postoperative LSG patients.

We performed a retrospective review of 213 consecutive patients that underwent LSG at a single institution between January 2008 and October 2012. There were 97 operations completed with Duet staple line buttress reinforcement, and 116 operations that used the Covidien TriStaple system. Our primary outcomes were staple line bleed or leakage. Secondary outcomes included wound infection, hematoma, upper GI bleeds, cardiopulmonary complications, and operative time.

Both patient cohorts had similar baseline demographics. The mean patient age was 44.4 (+/-9.2) and 44.3 (+/-9.5) years (p=0.938), and preoperative BMI was 44.9 (+/-9.3) and 44.3 (+/-6.9) kg/m2 (p=0.78) for the tri-staple and buttress group respectively. Our primary outcome of gastric leak was not met in either group, and the rate of gastric bleeding was not significantly different between the TriStaple and buttress group (0 vs. 1; p=1.00). We found no significant difference between the TriStaple and buttress groups in regards to wound infection (1 vs. 4; p=0.379), hematoma (1 vs. 0; p=0.455), upper GI bleeds (0 vs. 1; p=1.00), or cardiopulmonary complications (0 vs. 1; p=1.00). Interestingly, we found that the OR time was significantly shorter in the TriStaple group (80 +/-22 min) than in the buttress group (96 +/-25 min) (p<0.001).

Both the TriStaple and the Duet Tissue Buttress system are safe and efficacious options for managing the staple line in a laparoscopic sleeve gastrectomy, as both show low rates of postoperative complication. We found no significant differences in gastric bleeds or leaks between the two systems. Due to the low incidence of these complications, further studies with larger patient populations and randomization are needed to detect differences between the two systems.

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