BMI

In Part One, we came to the reluctant conclusion that the sleeve, safe procedure though it is, has a near 3 percent leak rate. Incidentally, the two of us at BMI have not yet had a leak in nearly five years of practice. For whatever reason though it may be (luck?), we would like to think it is because of our superior technique!

We need to now examine why these leaks occur. Is it the make of the stapler?

All over the world, surgeons use either the Ethicon stapler (called Echelon) or the Covidien product (the legendary endo-GIA). In our experience, while both are world class products, the mechanical problems arise with reuse of the stapler guns. In India, not many patients want to pay for a new gun. Surgeons also tend to give lower packages in an effort to be patient-friendly, thereby giving short shrift to a new gun (something that may cost nearly 20,000 to 30,000 INR, or in the vicinity of 400-500 USD).

If you reuse a gun beyond its shelf life, you can have misfirings during the operation. This is a ghastly experience which no surgeon should have. I have even had occasions where the stapler failed to unlock after firing! Clearly, no surgeon should allow a situation like this to happen, but how can he prevent it? After all, the stapler gun doesn’t say, “Don’t use me now, I am gonna die!”

What I say now may be controversial, but this is my humble experience of using laparoscopic staplers over a decade. The Covidien gun tends to work better with reuse, while the Echelon stapler works best when new. If I use the latter product in a case, I make sure I buy a new gun and throw it off (after all, these products were not meant to be reused!) after the case. Obviously, this pushes up the cost of the operation, but what can we do except to hope that the patient understands the reasons?

To come back to the point, reusing staplers is a tricky and potential troublesome issue. I have found no evidence in the scientific literature linking leak rates with reuse, but I suspect that there may be a relationship in some cases, at least.

In a personal communication with the authors of the Chilean paper I referenced in Part One, they opine that leak rates may be related to thermal injuries. This means that when we seal off and divide the blood vessels of the stomach, we may cause some heat injury to the wall of the organ. If such a part is left behind (rather than removed as part of the specimen) it may leak in the post-op period.

Another mechanism of leak: if the gastric tube is too narrow at the region of the body ( a point called the incisura) the resultant increase in pressure in the upper part of the stomach tube may lead to a blowout at the most vulnerable part above. This is usually at the junction of the food pipe and the stomach (the GE junction). This is borne out in clinical practice. The commonest site of a leak is the GE junction.

Another site of a leak could be the junction between adjacent staple cartridges. This is why it is considered important to oversew these junctions.

Does oversewing the staple line prevent leaks? We all think it  does, which is why practically all of us do so. However, as this Czech paper says, it may be unnecessary in most cases.

How do we detect leaks?

During the operation, we check the staple line by pushing in methylene blue dye into the stomach. A leak will be seen if present. Some people use an endoscopic verification of the staple line.

After the operation, a contrast (dye) study usually done just before liquid diet is started may be done, especially if intraoperative checks were not done, or a leak was detected and corrected at that time.

Does using staple line reinforcement reduce leaks? As this literature review says, no.

Which patients are more prone to leaks?

While the heaviest middle-aged male smokers are the stereotypical ‘bad’ patients, those who undergo revision surgery (for example, a sleeve with a band removal) are more liable to leaks.

How is a leak managed?

1. Ensure drainage of the peritoneal cavity (percutaneous, CT-guided drainage versus laparoscopic surgical placement of a drain)

2. Endoscopic stent to cover the leak, though a stent may migrate and be unsatisfactory in a given situation.

3. Suture closure of the leak after re-exploration of the abdomen.

4. Parenteral or enteral nutrition.

5. Mere observation in given patients

In most instances, the leak takes several weeks to dry out fully, and this results in prolonged hospitalisation and increased costs as well.

The important thing about leaks is to detect it early, as clinical examination in the severely obese is notoriously unreliable.

Useful references:

1. ASMBS position paper on Sleeve Gastrectomy 2009

2. Canadian overview on Sleeve Gastrectomy

3. World Journal of Gastroenterology 2008 Editorial