Michel Vix, MD, Ludovic Marx, MD, Michele Diana, MD, Silvana Perretta, MD, Gianfranco Donatelli, MD, Cosimo Callari, MD, Valérie Podelski, MD, Jacques Marescaux, MD Hon FRCS FACS Hon JSES. IRCAD, University of Strasbourg, France
Laparoscopic Sleeve Gastrectomy (LSG) is gaining acceptance as a definitive bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities. A specific and potentially severe complication of LSG is the staple line leakage (SLL) that may occur in up to 7% of cases. Technical errors, stapling line crossing, poor vascularization, and gastric inflammation are the potential underlying mechanisms of this feared complication. No preventive measures were clearly identified at this point.
The aim of this study is to analyze the rate and management of SLL in a prospective cohort of LSG.
Patients and Methods
Between July 2005 and July 2011, 378 patients (319 women/59 men) underwent LSG performed by chief residents (n=287) and a senior consultant in bariatric surgery (n=91). A five trocar technique was used. After mobilization of the greater curvature of the stomach the gastric resection was performed by successive firings of 4.5 mm-high staples (Endo GIA™ 60 mm) at the antrum and 3.5 or 4.5 mm-high staples at the gastric body and fundus towards the left diaphragmatic crus, depending on the thickness of the stomach. A 36F bougie was used to calibrate the gastric tube. The staple line was systematically reinforced with a running suture. All patients received a standardized post-operative care protocol including Proton-Pump Inhibitors and Thromboprophylaxis. Patients were on liquid diet from Postoperative day (POD) 1 to POD15.
Staple line leakage occurred in 9 patients (2.38%), at the level of the cardia in all cases. The first leak occurred after 131 consecutive uneventful procedures. Rate of fistula was 6/287 and 3/91 after procedures performed by chief residents and senior respectively (p: 0.25). No demographic data were found as potential predictors of SLL. Mean Charlson Comorbidity Score was higher in patients presenting a leak (1.84 vs. 1.37) but score classes were equally distributed in both groups. Patients were managed by combined laparoscopic (n=2) or open (n=1) exploration, drainage and endoscopic self-expandable covered stent (SECS), CT-guided percutaneous drainage alone (n=2) or a SECS alone (n=4). Medical support including total parenteral nutrition and adapted antibiotics was started in all the patients. Patients with SLL had a longer mean length of hospital stay (LOS) (19 days; range 3-56 vs. 3 days 3-5); and required multiple re-admissions (mean 2.85, range 1-6), which represents a mean of 29.28 additional hospital days. Median LOS according to the treatment modality was 41 days (range 26-56) vs. 18 (range 3-33) vs. 7 (range 5-16) in the surgical drainage + stent vs. percutaneous drainage vs. stenting alone groups respectively.
The combined treatment modalities were successful in all the cases and patients were totally asymptomatic at the follow up.
Staple line leakage, which occurred in 9/378 (2.38%) of our patients, is a severe and unpredictable complication of LSG. Experience has demonstrated that endoscopic stenting is a key-point of the management of SLL, combined eventually with other treatment modalities.
Session Number: SS09 – Obesity Surgery
Program Number: S049