|Year : | Volume
| Issue : | Page :
Safety of peripheral gastric vessel coagulation during laparoscopic sleeve gastrectomy
Jian Hong, Jason Widjaja, Ponnie Robertlee Dolo, Libin Yao, Xiaocheng Zhu
Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
|Date of Submission||02-Jan-2021|
|Date of Decision||10-Feb-2021|
|Date of Acceptance||16-Feb-2021|
|Date of Web Publication||30-Mar-2021|
Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002
Source of Support: Natural Science Foundation of Jiangsu Province (2015102015), Conflict of Interest: None
Introduction: Staple-line bleeding (SLB) is a common issue during laparoscopic sleeve gastrectomy (SG). Identifying a method or technique intraoperatively to manage or reduce the prevalence of SLB is crucial.
Materials and Methods: Patients' data who had undergone primary laparoscopic SG from January 2018 to December 2019 at our hospital were retrospectively analysed. The patients in this study received peripheral gastric vessel coagulation intervention in addition to the standard SG procedure. Preoperative parameters included age, gender, body mass index (BMI), the prevalence of diabetes and hypertension. Intra- and postoperative parameters were prevalence of SLB, operative time, total postoperative stay, the prevalence of leakage and bleeding. Intraoperative SLB was identified and analysed through video recordings.
Results: 217 cases of laparoscopic SG were included in the study. The mean preoperative assessments were as follows: age, 34.2 ± 10.7 years; male/female, 98/119; BMI, 39.9 ± 7.6 kg/m2; prevalence of diabetes, 52 (24.0%) and hypertension, 90 (41.5%). Of 217 patients, 35 (16%) were found to have SLB following the new interventional procedure. The mean operative time was 93.2 ± 13.6 min. The mean total postoperative stay was 3.3 ± 1.3 days. The postoperative prevalence of leakage and bleeding were 0% and 0%, respectively.
Conclusion: The technique of coagulating the peripheral gastric vessels to prevent SLB is safe and appears promising. A prospective study comparing with and without peripheral gastric vessel coagulation will be needed in the future.
Keywords: Bariatric surgery, bleeding, complication, sleeve gastrectomy, staple line
| ¤ Introduction|| |
Obesity is a worldwide chronic disease. The World Health Organization reported that in 2014, 11% of adult men and 15% of adult women suffered from obesity. Bariatric surgery is one of the many treatments available to combat obesity, and the data reported that bariatric surgery is gaining more and more popularity. In bariatric surgery, sleeve gastrectomy (SG) has become the preferred bariatric procedure, presumably due to technically less demanding. However, complications following SG procedure do occur and may at times debilitating.
Bleeding is one of the possible intra- and postoperative SG complications. The bleeding source can usually be traced from the staple line, injury to the abdominal wall, omentum and the short gastric vessels. One study reported that bleeding following SG mostly occurred on the staple line. In this study, we propose a simple and applicable technique that might have the efficacy to reduce staple-line bleeding (SLB).
| ¤ Materials And Methods|| |
This study was approved by the ethics committee and institutional review of our hospital and was compliant with the Helsinki declaration. All patients have signed the informed consent regarding the benefits and risks of laparoscopic SG before the surgery.
Patients' data from January 2018 to December 2019 who had undergone bariatric surgery at our hospital were retrospectively analysed. Inclusion criteria were (1) performed SG as the primary bariatric surgery; (2) age, 18–65 years and (3) body mass index (BMI), ≥BM.5 kg/m2. All of the patients included in this study have not received previous abdominal surgeries (including bariatric) nor being complicated with other diseases (such as neurological or malignancy diseases).
Preoperative parameter assessment includes age, gender, BMI, the prevalence of diabetes and hypertension. Intra- and postoperative assessments were prevalence of SLB, operative time, total postoperative stay, the prevalence of leakage and bleeding. Intraoperative SLB was identified and analysed through video recordings by two surgeons. SLB was defined as the presence of bleeding that was 'oozing' or 'pulsing' along the staple line.
Sleeve gastrectomy procedure
The standard technique for laparoscopic SG was used for all the patients. The same chief surgeon performed all of the surgical procedures. Either 5-port (12 mm, 10 mm, 10 mm, 5 mm and 5 mm) or 4-port (12 mm, 10 mm, 5 mm and 5 mm) laparoscopic SG was performed in all of the patients. Patients with BMI B35 kg/m2 underwent 5-port, while those with BMI <35 kg/m2 underwent 4-port laparoscopic SG.
Our SG procedure has been described previously. However, in summary, five stapler firings (Ethicon Echelon Flex Powered Endopath 60 mm) were taken to complete the sleeve (cartridge used from the first to last were: Green, yellow, yellow, blue and blue). The staple line was buried through continuous suture using Covidien 3-0 V-Loc.
Peripheral gastric vessel coagulation
In addition to the standard SG procedure, we coagulated the peripheral gastric vessels using either harmonic (HARMONIC ACE +7 Shears in Advanced Hemostasis, Ethicon) or LigaSure (LigaSure Maryland, Covidien) sealing device [Video 1].
A histology study using haematoxylin and eosin stain (HE stain) was performed on ten patients, randomly chosen, through their resected stomach specimens. The aim was to histologically observe the blood vessels of the stomach (whether our coagulation technique might induce ischaemia to the stomach).
All data were presented as mean ± standard deviation or as otherwise mentioned. Statistical Product and Service Solutions (SPSS 20.0) SPSS Inc., Chicago, IL software was used to calculate the statistical analysis. P < 0.05 was considered statistically significant.
| ¤ Results|| |
Two hundred seventeen cases of laparoscopic SG were performed from January 2018 to December 2019 at our hospital. The mean preoperative assessments were as follows: age, 34.2 ± 10.7 years; male/female, 98/119; BMI, 39.9 ± 7.6 kg/m2; prevalence of diabetes, 52 (24.0%) and hypertension, 90 (41.5%) [Table 1].
All procedures were successfully performed without the need for conversion. There were no early or late morbidity and mortality. Discharged patients were advised to take oral omeprazole for 1 month and daily supplementation of multivitamins.
Intra- and postoperative assessments
Thirty five (16%) out of 217 patients were found to have SLB immediately following stapler firing [Table 2]. Electrocautery or additional peripheral gastric vessel coagulation (for those vessels that might have been missed earlier) were used to manage these SLB incidences. Before closing (after suturing to bury the staple-line) the staple line and the whole abdomen was re-inspected for bleeding. No obvious bleeding was observed in all patients before closing.
The mean operative time was 93.2 ± 13.6 min. The mean total postoperative stay was 3.3 ± 1.3 day. The postoperative prevalence of leakage and bleeding were 0% and 0%, respectively.
Our histology study using HE staining found numerous blood vessels in the gastric submucosal layer [Figure 1]. Therefore, our technique might not cause ischaemia to the remnant gastric sleeve.
|Figure 1: Histology study showing the gastric vessels. Triangle: The gastric vessels affected by the coagulation (serosa), Star: Submucosal gastric vessels|
Click here to view
| ¤ Discussion|| |
At the current preliminary step, we believe that this novel technique of coagulating the peripheral gastric vessels to prevent SLB is safe and merits further evaluation.
The peripheral gastric vessel coagulation technique was invented during a case where a spurting SLB had occurred. Instead of using electrocautery or clipping the staple-line, we quickly attempted to coagulate the blood vessel nearby the SLB. This simple intervention interestingly stopped the spurting SLB, and we have since then used it as a standard preventive measure for the rest of our patients. [Figure 2] provides a better illustration. Video 2 also demonstrates another case where SLB might be related to the peripheral blood vessel [Video 2].
|Figure 2: Staple-line bleeding that is directly related to the peripheral gastric vessels (a: 'pulsing' bleeding can be seen clearly; b: the bleeding stops following the vessel coagulation)|
Click here to view
Ischaemia due to the coagulation of the peripheral gastric vessels is a concern initially. However, through our histology study, it appeared that the peripheral vessels and the submucosal vessels are independent of each other [Figure 1], which suggests that the peripheral gastric vessel coagulation might not induce ischaemia. Furthermore, postoperatively, there were no morbidities related to this intervention in any of the patients.
One study reported that SLB during SG procedure occurred mostly in the gastric body, within the second to fourth staple firings. Hypothetically, this report fits with our technique's concept (peripheral gastric vessel coagulation) as the gastric vessels are indeed found most in the lesser curvature part within the second to fourth staple firing areas [Figure 3].
|Figure 3: The gastric vessels seen during the third stapler firing (a, anterior; b, posterior)|
Click here to view
Various technical improvements such as the proper selection of cartridge, firing technique and staple-line reinforcements (note: various staple-line reinforcement materials such as buttress might not be available in some countries) can reduce the rate of SLB., When SLB occurred, it increases the operating time and the risk for reoperation. To manage SLB, several techniques such as the use of clips, electrocautery, haemostatic gauze and lowering the blood pressure can be used. Furthermore, the patient's condition itself (e.g. hypertension, abnormal clotting factors and smoking history) might increase the bleeding rate.
We believed that our proposed technique of coagulating the peripheral gastric vessels as a preventive measure for SLB merits further evaluation. This technique might also potentially become a standardised practice complimenting SG as it is applicable and easy to learn. This technique can be performed rather swiftly and without additional cost (i.e., buttress, clips and drugs). On the other hand, this technique can also be used in conjunction with buttress or clip usage in an attempt to further control/prevent SLB. Furthermore, for surgeons who preferred to reinforce the staple line by suturing, this technique might prevent further bleeding caused by iatrogenic injury to the peripheral vessels.
In our prior experience where we did not coagulate the peripheral gastric vessels, SLB was observed in 38% of 108 patients (with 4 cases of postoperative bleeding), much higher than the current study (unpublished data). However, the learning curve could likely be a culprit; therefore, comparability might be an issue.
This study is limited due to no comparison (prospective study). Thus, it is still challenging to decide the effectiveness of this technique in preventing/managing SLB. A further prospective study comparing the SLB incidence for with and without peripheral gastric vessel coagulation will be crucial before absolute judgement. However, at this preliminary stage, this technique seemed safe and sounds promising.
| ¤ Conclusion|| |
This novel technique of coagulating the peripheral gastric vessels to prevent SLB is safe and appears promising. A prospective study comparing the efficacy for with and without peripheral gastric vessel coagulation will be needed in the future.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
For this retrospective study, additional formal consent is not required.
Informed consent was obtained from all individual participants included in the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Natural Science Foundation of Jiangsu Province (2015102015).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]