Staple Line Reinforcements and Bleeding Rates in Laparoscopic Gastric Sleeve Procedures: Are These Buttress Materials Worth the Cost?

Shoshana Hacker, MD, Eric Micallef, BS, Karleena Tuggle, MD, Titus Duncan. Atlanta Medical Center

Introduction: Mechanical stapling devices are routinely used in bariatric surgery however a well known complication is bleeding. Many buttress materials have been developed in an effort to reduce bleeding. Peri-Strips Dry is a biological tissue derived from bovine pericardium that acts as a buttressing material to the staple line. It has been advocated as an essential tool in bariatric surgery.  However the data in regards to decreasing bleeding in the gastric sleeve procedure with this product is still controversial.

Hypothesis:  There is no significant difference of staple-line bleeding rates in laparoscopic gastric sleeve procedure with the use of Peri-strips Dry versus no Peri-Strips Dry and instead lowered pneumoperitoneum to better evaluate and treat staple-line integrity.

Methods: A retrospective analysis of 314 patients that underwent laparoscopic sleeve gastrectomy between May 2014 to August 2015 at a bariatric center of excellence was conducted. Cases were divided into two groups: with Peri-Strips Dry and without its use. 140 cases were performed with the use of Peri-Strips Dry and 171 cases were done without its use. In the cases without the use of the Peri-Strip Dry; the pneumoperitoneum was decreased to 10 mmhg after resection and the staple line was examined for any bleeding. If bleeding occurred hemostasis was achieved by electrocautery or over sewing the staple-line. A staple line bleed was considered significant if it required a re-operation or blood transfusion.

Results:  Fewer staple-line bleeds were observed in the Peri-strip Dry group (1/140 [0.7%] vs. the no Peri Strip Dry group (4/171 [2.34%]) however these findings were not significant with a Z score of 1.1335 and a p- value of 0.258. For the patients in the no Peri-Strip Dry group that had bleeding three required a re-operation and the other a blood transfusion. There were no deaths in all the cases.

Conclusion:   There was no significant difference of staple-line post operative bleeding rates in laparoscopic gastric sleeve procedure with the use of Peri-strips Dry versus no Peri-Strips Dry and instead lowered pneumoperitonueum to better evaluate and treat staple line integrity.  The additional cost to the laparoscopic gastric sleeve procedure due to the use of Peri-Strips Dry is around $1500 per case. Therefore we must pose the question: if hemostasis can adequately and safely be prevented without the use of buttress material then is it worth the additional cost to the patient?

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