Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a widely utilized and effective surgical procedure for dramatic weight loss in obese patients. Leak at the sleeve staple line is the most serious complication of this procedure, occurring in 1–3% of cases. Techniques to minimize the risk of sleeve gastrectomy leaks have been published although no universally agreed upon set of techniques exists. This report describes a single-surgeon experience with an approach to sleeve leak prevention resulting in a progressive decrease in leak rate over 5 years. Methods. 1070 consecutive sleeve gastrectomy cases between 2012 and 2016 were reviewed retrospectively. Patient characteristics, sleeve leaks, and percent body weight loss at 6 months were reported for each year. Conceptual and technical changes aimed towards leak reduction are presented. Results. With the implementation of the described techniques of the sleeve gastrectomy, the rate of sleeve leaks fell from 4% in 2012 to 0% in 2015 and 2016 without a significant change in weight loss, as depicted by 6-month change in body weight and percent excess BMI lost. Conclusion. In this single-surgeon experience, sleeve gastrectomy leak rate has fallen to 0% since the implementation of specific technical modifications in the procedure.

All cases of sleeve gastrectomy performed by a single surgeon were reviewed over a 5-year time period, under an IRB-approved protocol. A comprehensive review of the literature of sleeve gastrectomy leak was undertaken. We report 1070 consecutive cases of laparoscopic sleeve gastrectomy and the rate of gastric staple line leak over the time from January 1, 2012, to the end of 2016. The last cases included in the analysis took place in December of 2016 and were monitored for evidence of leaks through March of 2017.

All patients were evaluated with nutritional and psychological evaluations and medical and specialist evaluations in accordance with the nationally accredited center’s protocol. Each patient underwent evaluation with either upper GI series or esophagogastroduodenoscopy and responded to clinical questions regarding the presence or absence of GERD symptoms. 18% of patients were diagnosed with hiatal hernia preoperatively and repaired concomitantly with the sleeve, and an additional 9% were diagnosed intraoperatively and repaired. In all cases, the baseline sleeve procedure was performed with laparoscopic technique. After insertion of four trocars, a Nathanson liver retractor was placed to elevate the left lateral segment of the liver. A bougie calibration tube was placed along the lesser curvature, and the greater curvature blood supply was divided with radiofrequency sealing, beginning 5 cm from the pylorus. Three Echelon green stapler cartridges were utilized in the antrum, using staple line reinforcement of bovine pericardium (Peristrips). The gastric body and fundus were stapled with varying Echelon stapler cartridges, which became consistent after 2014 with two gold cartridges in the mid body followed by two blue cartridges in the proximal fundus. The left crus was fully exposed. The most proximal stapler was angled 2-3 cm away from the esophagus. The hiatus was repaired with anterior cruroplasty without posterior dissection when a hiatal hernia less than 3 cm was present and with hiatal dissection and anterior and posterior cruroplasty when >3 cm. A methylene blue leak test was performed at the end of the procedure.