New leak study

[Avonlea]

FYI, pubmed shows a new VSG survey study about leaks. Not surprisingly, these super tiny sleeves some surgeons push come with a higher leak risk. I thought it was interesting that they reported a .6% leak rate with a 40f or greater bougie compared to 2.8% for under 40f. That's a pretty big difference.

www.ncbi.nlm.nih.gov/pubmed/22179470

METHODS: An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.

RESULTS:
The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI < 50 kg/m(2). Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful.

CONCLUSIONS:
Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m(2)) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge.

[Deleted]

Thank you for posting this. It covers a lot of ground with some interesting observations. While a large chunk of the collective studies groups had few leaks, it is no surprise that smaller sleeve sizes are one factor that can possibly be tied to a higher % of leaks.. though they even note this is just a door-opener, not a controlled study with firm conclusions.

The great majority of these publications are retrospective chart review case series.
By definition, this makes comparison of the data and its
analysis difficult and the conclusions drawn significantly less
strong than a blinded, randomized, control trial. However,
we feel very strongly that the information, trends, and differences found from the analysis of these publications provide significant information to direct further study on the
topic and perhaps safer surgery with fewer complications.

I did find the staple size bit to be very interesting, something perhaps pre-ops should also inquire about when interviewing a possible surgeon. There also seems to be a wide variation in skill perhaps.. *I am not a good interpreter of studies, in general, so hoping someone who is will pop in and pick this one apart so we can better digest the conclusions* ..when one large group has no leaks, and another represents .7-7% that is a big swing..

From the Medline search, 29 publications provided 4,888
patient records. The mean BMI ranged from 34 to 65.4 kg/m
2
.
All 29 studies documented a leak rate, which ranged from 0 to
7%. The mean leak rate for all 29 studies was 2.4%, which
accounted for 115 leaks in 4,888 cases of sleeve gastrectomy.
Six studies specifically addressed super-obese patients with a
mean BMI[50 kg/m
2
[1, 4–6]. In the super-obese, the mean
leak rate was 2.9% or 23 leaks of 771 patients compared with
the leak rate of only 2.2% (92/4,117) for those with mean
BMI\50 kg/m
2
(not significant P[0.05).
Seven studies boasted no leak. These studies had a total
of 1,151 patients. Their mean BMI range was 43–58 kg/
m
2
. They used different bougie sizes from 32- to 48-Fr to
size their sleeves, and only one used staple-line buttressing
material; however, two of the other six oversewed their
staple lines. These leakless groups for the most part used
two sizes of staples: 4.1–4.5 mm on the distal stomach
(antrum) and 3.5 mm on the proximal body and fundus. Of
these seven leakless publications covering 1,151 patients,
there were only three bleeds and one stricture, which
required reoperation. All seven publications demonstrated
significant excess weight loss [50% at 12 months (only
two reported as EWL the others as excess BMI loss).
Twenty-two studies documented a leak, and this ranged
from 0.7 to 7% and represented 115 of 3,737 patients. The
n ranged from 53 in a U.S. study to 540 patients in a
Spanish study.

[Avonlea]

I thought the staple size study was interesting, too. I plan to ask my surgeon about it.

I think the focus on bougie size by prospective patients is a little weird, in any case. It seems to be that people should be focusing on stomach volume, if they're going to fixate on anything. You can use a bougie of a certain size, but how large the stomach ends up will depend on technique.

I'm pretty skeptical of the trend to super-small stomachs in any case. I just don't see the evidence for it. VSG evidence is fairly paltry anyhow, but there really isn't any evidence as far as I can tell that would advise a super small stomach.

[Michelle J]

Interesting read. Thanks for posting this.

[Deleted]

Dec 27, 2011 22:37:17 GMT -5 Avonlea said:

I thought the staple size study was interesting, too. I plan to ask my surgeon about it.

I think the focus on bougie size by prospective patients is a little weird, in any case. It seems to be that people should be focusing on stomach volume, if they're going to fixate on anything. You can use a bougie of a certain size, but how large the stomach ends up will depend on technique.

I'm pretty skeptical of the trend to super-small stomachs in any case. I just don't see the evidence for it. VSG evidence is fairly paltry anyhow, but there really isn't any evidence as far as I can tell that would advise a super small stomach.

It def depends on technique and anatomy as well, longer vs shorter stomachs will effect the end volume once the swelling goes down, and the scar tissue softens and relaxes a bit.. Volume early out is not the same as what you will have 1-3 yrs PO.. the stomach does dilate a bit as it heals.

I am waiting (hoping) to see some studies soon that have been hinted/promised that include medium-term follow-up on regain based on sleeve size.. the hinted results are that the smaller sizes do show a lower amount of regain due to the amount of retained fundus. but I will reserve judgement until I see the numbers!

I have a 36F, oversewn (interesting suturing the staple line was linked to a higher stricture rate.. and FYI, my surgeon switched from a smaller size to the 36f as in his practice he saw a lowered incidence of issues with the slightly larger 36f, he was doing 32f iirc..) I have similar restriction to some 32f's, and other 32f's have a much higher volume.. so I generally throw most of that boughie stuff in the pile of "interesting, but perhaps not vital, when you account for all variables."

In reading some lit pre-op, there was a study (I will try to find it) that showed a possible link to regain issues with sleeves that leave too much fundus/ esp. fundus at the pyloric end, which tends to expand over time. I do think the amount of fundus left behind WILL effect your life-long capacity, and there have been several people who needed to be resleeved for this reason, or chose to re-sleeve and revise to DS.. So, while not a fan of "tighter is best" as I too think it CAN increase risks, there is some wisdom to not go too far in the opposite way and try and get an overly large stomach to start either.

I realize my capacity for solid protein right now is 2oz, most at a some years out report it maxes out around 4-6oz (meat again, not soft stuff).. That's with starting out smaller/tighter, as most that responded to my question back then started with the standard 32-38f. Large or incorrectly formed, I have seen a couple on the revisions board report almost nil restriction at 3 yrs PO.

There is a talk that Cirangle gave that if I recall- touches on sleeve size slightly, but again.. it is not a clear-cut longer range study by any means, just something noted.. I'm posting the link to the talk, but I cannot play it on my compy it needs to have some software added to play and I don't feel like messing with it right now, so my memory may not be accurate, it's been almost a year since I watched it.

www.ssat.com/video/2008/SSAT%2049th%20Annual%20Meeting(3)-Cirangle.htm

Logically I can understand that smaller differences early out may not create a statistically significant difference in EWL at the end of the first year.. but something in the back of my brain does tell me that (for me) having a smaller capacity into maintenance and for life would help me maintain easier.. and that leaving excess fundus will create more volume that I'd prefer not to have.

Ok, enough rambling from me.. but I really do enjoy talking about this sort of thing..

[Carolyn H.]

I also have a 36F oversewn, and my capacity at 11mo post-op is 2 1/2oz of dense protein (if I try hard). My surgeon also only uses a 36F. He feels that it's the 'sweet spot' for a sleeve in terms of size and relative risk. I can't complain

Dr. Cirangle's 2007 study suggested better results with a 32F bougie and he is supposedly going to release his follow-up that back it up; however, it's not out yet.

The more of the fundus that's removed the more ghrelin removed (apprently 70% of the body's ghrelin is produced in the stomach, most of which comes form the fundus), but I posted a study on OH that showed that even with a 48F bougie serum ghrelin remains significantly lower in VSG patients at 6 mo than pre-op.