Tri-stapler Technology Reliability in Construction of Gastric Sleeve: An Analysis of 90-Days Outcomes

Murad Bani Hani, MD, Ashraf Haddad, MD, Nadeem Haddad, MS, Dominic Nelson, MS, Andrew Averbach, MD

St. Agnes Hospital

Introduction:
Vertical Sleeve Gastrectomy (VSG) is seemingly a simple procedure which can be associated with significant morbidity (bleeding, leaks, and strictures). Certain technical aspects were suggested to reduce it, including the utilization of particular staplers and staple line reinforcement methods. Ethicon staplers are favored due to reportedly more reliable staple lines. In 2010 the Endo GIA Tri-stapler technology was introduced. The purpose of this study was to evaluate the reliability of the Tri-stapler technology in constructing the VSG.

Patients and Methods:
One hundred and six patients were included in a retrospective analysis of VSG outcomes. The mean preoperative weight and body mass index were 317.9 ± 75.2 lbs and 49.6 ±8.1. Seventy-five percent of the patients were females. A six port approach (two– 5 mm and three – 12 mm and Nathanson retractor) was utilized in all cases. Initially the greater curvature was mobilized from within 5 cm from pylorus to angle of His with full dissection of the left part of pars flaccida and exposure of left diaphragmatic crura with transection of posterior gastric artery. A 40 Fr bougie was used. After full mobilization, the stomach was transected obliquely through the application of Endo GIA purple 60 mm cartridge keeping it 4 cm away from the incisura angularis. Subsequent applications of purple 60 mm cartridges were done staying close on the bougie. Staple lines were crossed when needed for optimal sleeve construction. Excessive tension on the greater curvature was avoided. In the subcardia and angle of His, the stapler was moved laterally from the bougie edge for additional 1 cm. The staple line was inverted with sero-muscular running 2.0 Surgidac Endostitch. The hiatus was examined for the presence of a hernia that was repaired when detected with an anterior or posterior cruroplasty.

Results:
There were no episodes of stapler misfire. In 2.8% of cases there was slight cracking of the sero-muscular layer in the antrum. Simultaneous procedures were done in 78% of cases. Mean operative time was 103 ± 27.4 minutes for all cases, 98 ± 25.8 minutes for VSG only and 112 ± 23.8 minutes for VSG with hiatal hernia repair. Operative time for revisions from gastric band to VSG (6 cases) was 120 ± 39.5 minutes. Mean blood loss was 64 ± 43.1 cc with no transfusions. Thirty-day morbidity was 4 % with no leaks. One patient required re-laparoscopy for incarcerated ventral hernia from previous surgery. Average length of stay was 2.2 days. Re-admission rate within 30-days was 5%. Within 60 days 3 patients required upper endoscopy with balloon dilatation for “functional” stricture due to sleeve angulation. One patient (male, BMI 50) presented with delayed leak and a subdiaphragmatic abscess that required laparoscopic drainage 2 months after surgery (90 days morbidity 5.6%, leak rate 0.99%, reoperation rate – 1.88%).

Conclusion:
VSG utilizing the Tri-stapler purple cartridges with inversion with sero-muscular sutures is associated with a reliable staple line construction and low morbidity. It appears to be universally applicable to a variety of clinical situations associated with VSG.

Session: Poster Presentation

Program Number: P459