Inadvertent stapling of the orogastric tube during bariatric surgery

Abstract

Background: Entrapment of an orally introduced tube by stapling/stitching is an intra-operative complication of bariatric surgery with grave consequences. Incidence is unknown. No prevention/management strategy is available. A systematic review was performed to assess the absolute reported observed risk and incidence. Additionally, data on 3 cases during our entire sleeve gastrectomy (SG) experience is evaluated. Methods: Literature is reviewed using PubMed/Web of science data-bases. Data was recorded prospectively. Videos of orally introduced tube staplings were re-watched, presentation/recognition/management were re-evaluated. A protocol ensuring the removal of the small caliber orogastric tube (OGT) by the surgeons direct inspection was introduced after the 3rd entrapment. Results: Review revealed OGT as the most commonly entrapped tube following temperature probe and bougie. SG/stapling were the most common causative operation/reason, respectively. Leak rates over 20%, conversion, early-late re-operations and mortality were reported. During our 948 consecutive SGs, 3 OGT entrapments (0.32%), third one with double stapling, occurred. All were recognized/managed intraoperatively by freeing the entrapped-end of the OGT from the sleeve part of the staple-line. In doubly stapled case, second transected end could only be recognized when routine reinforcement suturing come in proximity. Defects were continuously stitched with barbed suture. No morbidity occurred. One-year excess-weight-loss was 82%. A pre-protocol incidence of 0.56% (n: 3/534) dropped to nil in the remaining 414. Conclusion: Iatrogenic stapling of the OGT during SG is rare, but morbid. It must be avoided by a strict protocol. Upon occurrence/recognition, stapling must immediately stop until the “entirety” of the tube, including the “specimen-part”, is retrieved, to avoid double entrapment.

Laparoscopic vertical sleeve gastrectomy in felines: A cadaveric feasibility study and experimental case series in two cats

“…While we did not encounter the complication of stapling through the orogastric tube in our cadaver specimens or live patients, this has been reported in human medicine 19 . Because of this, more robust specialized bougie tubes (Visigi3D bougie, Boehringer Laboratories, LLC, Phoenixville, PA, USA) are used in human bariatric surgery and may be considered in a larger live animal model.…”

Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies

“…The same material/technique was used for the repair of serosal tears and staple misfires (Video 4) as well as the staple-line bleedings requiring re-surgery (Video 3). Four defects related to the freeing of 3 inadvertently stapled nasogastric tubes in three patients were also repaired utilizing the same suturing material/technique and video footage has been recently reported [16].…”

“…Our protocols on bougie type/size/usage [16], preoperative workout/SG technique which are the same for all BMIs [17], and just recently, virus related changes during the Covid-19 pandemic have been reported [18]. A low pneumoperitoneum strategy which was continued during the pandemic [18] was already in place (Table 1).…”