Ye Tian, BA1, Jared Cappelli, RN, BS1, Hallie Nelson, BS1, Xinyi Shen, BS1, Ann M Rogers, MD, FACS2. 1Penn State College of Medicine, 2Penn State Hershey Medical Center
Introduction: Bleeding, leaks and surgical site infections are major indicators specifically measured and reported in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as they are not uncommon and can lead to increased morbidity, need for additional procedures and cost. Our MBSAQIP-accredited program was found to “need improvement” in the bleeding category compared to the national sample. As such, we investigated this in a search for remediable causes.
Methods: We performed a retrospective review of all patients undergoing primary laparoscopic sleeve gastrectomy (LSG) at a university hospital bariatric program from June 2008 through May 2016. Patients who experienced post-operative bleeding were identified. Indicators included need for blood transfusion, reoperation for bleeding based on clinical change, or hematoma identified by CT scan for pain within 30 days of primary LSG. Hypothesized causes for bleeding included chronic anticoagulation therapy (CAT), history of hematologic disease, history of deep vein thrombosis (DVT) or pulmonary embolus (PE), type of venous thromboembolism (VTE) prophylaxis, history of liver disease, concurrent development of post-operative DVT, and technical factors. Information was collected on preoperative age, sex, race, and body mass index (BMI). Medical records were reviewed to evaluate for technical mishaps or need for additional attention to staple line bleeding. Three fellowship-trained academic surgeons used an identical surgical technique, including a single dose of preoperative antibiotics, starting the staple line 6cm from the pylorus, using bioabsorbable staple line buttress material on loads taller than 3.5mm, and using a gastroscope approximating a 36Fr bougie for both sizing and a pneumatic leak test. Based on surgeon preference, the first antral stapler had an open height of 4.4 or 4.1mm, progressing through heights of 4.1, 3.5 and occasionally 2.5mm, based on tissue and stapler feedback. Bleeding and nonbleeding groups were statistically compared.
Results: Among 637 patients undergoing LSG, 13 (2.04%) experienced clinically significant postoperative bleeding. The mean BMI and age were not significantly different between groups. Nor was there statistical difference in history of anticoagulant use, coagulation disorder, history of or concurrent VTE, technical issues, or VTE prophylaxis between groups. There was, however, a significant difference in underlying liver pathology, with a much greater prevalence (53.8%) in the bleeding group.
Conclusions: Bleeding complications after LSG can add significant morbidity and cost. Technical errors and coagulation issues seem to be relatively unimportant compared to underlying liver disease, a factor difficult to control. Further study is warranted.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78794
Program Number: P488
Presentation Session: Poster (Non CME)
Presentation Type: Poster