Preventing Staple-Line Leak in Sleeve Gastrectomy: Reinforcement with Bovine Pericardium vs Oversewing

Abstract

One of the most serious, potentially life-threatening complications of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Oversewing the LSG staple line vs buttressing it with bovine pericardial strips (BPS) to reduce perioperative bleeding and postoperative gastric leak was evaluated. From 2006 through 2011, 160 patients underwent LSG with suturing as the only staple-line reinforcement (Group A). From March 2010 through August 2012, 84 LSG patients had BPS incorporated into their last two stapler firings (Group B). Staple lines were evaluated perioperatively for bleeding, and patients were monitored for indications of staple-line leaks (peritonitis, abnormal output from the drain). In preoperative Group A and B, there were 117 (73.1%) vs. 56 (66.7%) females; mean age, 35.2 years (18.0-68.0) vs. 33.8 years (15.0-64.0); mean body mass index (BMI, kilograms per square meter), 42.5 (27.0-76.0) vs. 42.0 (30.0-58.0). Three months after surgery, mean BMI for Group A was 37.3 (-5.9); Group B, 35.2 (-7.3); at 6 months, 32.7 (-10.8) and 31.5 (-11.3; p < 0.001). Although there was no significant difference in perioperative blood loss, oversewn staple lines in Group A often required electrocautery to stanch bleeding; this was not required for Group B. In Group A, 15 patients (9.4%) developed complications; in Group B, five (6.0%; p = 0.46). Gastric fistula, verified by barium swallow, occurred in eight Group A patients (5.0%); in Group B, one (1.2%; p = 0.17). Relative to oversewing, staple-line buttressing with bovine pericardium was readily accomplished, safe, and associated with a lower staple-line leak rate.

Buttressing the Staple Line: A Randomized Comparison Between Staple-Line Reinforcement Versus No Reinforcement During Sleeve Gastrectomy

“…The use of bovine pericardium strips has been shown to reduce staple-line bleeding, with fewer days of hospitalization compared with patients with no staple-line reinforcement [14]. Recently, Hajj et al 2013 reported that bovine pericardium strips were associated with a lower staple-line leak rate compared with over-sewing [19]. PSD-V, approved in the USA, has received the CE Mark (indicating product compliance with European Union legislation) and has recently been approved in India.…”

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management

“…Three meta-analyses and several systematic reviews have been published within the past 5 years on the use of staple line reinforcement with varying conclusions ranging from no significant effect on bleeding or leak, variable effect on leak depending on the material used for buttressing without assessment of bleeding and no effect on leak but decreased staple line bleeding. One review identified buttressing to be associated with an increased risk of bleeding [67][68][69][70][71][72][73][74][75][76]. There is one randomized controlled trial on the use of fibrin sealant during SG that reported a significant reduction in operative bleeding, although the clinical relevancy of this finding was not clear.…”

“…Leak incidence, however, was not found to be significantly different [77]. Most studies have not shown over-sewing to reduce the incidence of leak [67,78,79]. The heterogeneity of the studies, small statistical power, discrepancy of buttressing materials utilized and over-sewing methods in conjunction with varying staple heights and techniques (different bougie sizes) limit any recommendations regarding the use of these materials to prevent GI leak after SG.…”

A Comparison of a Single Center’s Experience with Three Staple Line Reinforcement Techniques in 1,502 Laparoscopic Sleeve Gastrectomy Patients

“…BPS has additionally been associated not only with decreased leak and bleeding rates but also with increased complications such as gastric fistula and infection [16][17][18]. Small prospective cohort studies comparing SLR techniques in LSG have found no significant difference in complication rates, but lack sufficient power [3,19,20]. A recent systematic review comparing APM, BPS, oversewing, and no reinforcement demonstrated that the leak rate in LSG was lowest with the use of APM [8], but this contrasted with a multi-institutional study that demonstrated the lowest leak rate with BPS [21].…”