Laparoscopic Sleeve Gastrectomy and Staple Line Leaks: Does Bougie Size Matter?

Ryan S Lohre, BSc, Ahmer A Karimuddin, MD, Bao Tang, MD, Bradley J Amson, MD, Samaad Malik, MD, MSc. University of British Columbia

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) for treatment of morbid obesity remains highly technically variable (bougie size, staple distance from pylorus, and staple length). This study evaluates clinical outcomes in patients receiving LSG over a one year period and investigates utilizing a bougie size of ≥40F reduces complication rates.

METHODS AND PROCEDURES: A retrospective analysis of all LSGs performed (2009-2014) by three bariatric surgeons at a single center. Patients included: age>18 years, BMI>35 kg/m2 with co-morbidities and BMI>40 kg/m2, while patients with revisional surgery were excluded. Preoperative patient parameters, excess of weight loss percentage (%EWL) up to one year, and surgical variables were analyzed.


Table 1. Bougie sizes <40F and ≥40F with mean values for patient parameters and complication rates.
BougieNM:FMean Age (SD)Mean Preoperative BMI (SD)%EWL 1 Month (SD)%EWL 3 Months (SD)%EWL 6 Months (SD)%EWL 1 Year (SD)Complications (n)Staple Line Leaks (n)
<40F12219:10351.7 (9.87)49.5 (8.17)20.6 (8.74)28.3 (13.4)35.7 (6.33)51.3 (14.1)133
≥40F9015:7548.3 (10.8)44.3 (6.22)13.6 (12.0)28.3 (13.6)40.5 (18.7)44.8 (9.27)00
Total (34F – 42F)21234:17850.1 (10.6)47.2 (7.9)16.7 (11.2)29.0 (14.1)38.6 (15.0)49.6 (13.1)133

Two hundred and twelve patients were included. Complications occurred in 6.0% of patients (n=13): 2.8% incisional hernias (n=6), 1.4% staple line leaks (n=3), 0.9% strictures (n=2), 0.9% acute renal failure (n=2), and 0.1% reflux (n=1). Total complication rates and staple line leaks were stratified towards preoperative age (p>0.05), gender (p>0.05) and super-obesity (BMI≥50 kg/m2, n=65) (p>0.05). Bougie size <40F (n=122) to ≥40F (n=90) was compared for predicting total complication rates (p=0.0008) and staple line leaks (p>0.05). Staple start distance from the pylorus <6cm (n=85) was compared to ≥6cm (n=120) for total complication rates (p=0.0001) and for staple line leaks (p=0.0698). Staple heights: 3.5mm and 4.8mm (n=26) vs 3.5mm staples (n=185) alone were compared for total complications (p=0.045) and staple line leaks (p>0.05). Total complication rates and staple line leaks was stratified towards a mean OR time of 75.6 (±29.9) minutes (p>0.05).

CONCLUSION: LSG is a safe and effective treatment for morbid obesity. Surgical characteristics of bougie size ≥40F, staple start distance from the pylorus ≥6cm, and use of only 3.5mm staples were all significant factors of total complication rates, with a staple start distance ≥6cm being nearly significant in predicting staple line leaks. Bougie size ≥40F provides comparable weight loss to bougie sizes <40F in the short term while having less morbidity.

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