Evaluating the Effect of Technique and Devices on Leaks after Laparoscopic Sleeve Gastrectomy

Oliver A Varban, MD¹, Ruth B Cassidy, MA², Kyle H Sheetz, MD¹, Amanda Stricklen, MS, RN², Carl Pesta, DO³, Jeffery Genaw, MD³, Arthur M Carlin, MD³, Jonathan F Finks, MD¹. ¹University of Michigan Health System, ²Center for Healthcare Outcomes and Policy, University of Michigan, MI, ³Henry Ford Health System

Objective: To assess the effect of technique and surgical devices on staple line leaks after laparoscopic sleeve gastrectomy (LSG).

Background: Staple line leaks after LSG are a major source of morbidity and mortality. Variations in technique and devices used to perform LSG exists, however their effect on leaks is poorly understood.

Methods: We performed a case-control study comparing patients who sustained a leak after undergoing a primary LSG to those that did not.  A total of 45 (0.40%) patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index (BMI), sex and year the procedure was performed. Technique and device specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population.

Results: Leak rates after LSG have decreased over the past 5 years (0.93% to 0.20%) despite variations in technique and device use. The only technique specific factor associated with a lower rate of leaks was oversewing of the staple line (OR 0.218, CI 0.071-0.672, p=0.008). Surgeons who oversewed routinely were also found to have higher case volume (307 vs 140, p=0.0216) and less overall complication rate (4.81% vs 7.95%, p=0.0027). Stapler vendor was associated with a higher rate of leaks on univariate analysis but not after controlling for confounding factors. Use of buttressing material, fibrin sealant and drains did not affect leak rates significantly.

Conclusions: Despite variations in technique, leak rates have decreased over the past 5 years. Oversewing of the staple line was associated with less leaks after LSG and was performed routinely by more experienced surgeons with less overall complication rates. Vendor, buttressing material, drains and fibrin sealant had no apparent effect. Surgeons should reconsider the use of superfluous and costly devices as a means of reducing leaks after LSG until further evidence justifies their use.