Technical Controversies in Laparoscopic Sleeve Gastrectomy

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1 OBES SURG (2012) 22: DOI /s REVIEW Technical Controversies in Laparoscopic Sleeve Gastrectomy Manuel Ferrer-Márquez & Ricardo Belda-Lozano & Manuel Ferrer-Ayza Published online: 23 August 2011 # Springer Science+Business Media, LLC 2011 Abstract Laparoscopic sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, many bariatric surgeons have adopted it in recent years with good results. However, there is still no standard procedure across different surgical teams. We will discuss the more controversial aspects of the surgical technique: the size of the bougie, the beginning of the distal section, the section shape at the gastroesophageal junction, the necessity and manner of reinforcing the staple line, and the routine use of intraoperative leak testing. Keywords Sleeve gastrectomy. Laparoscopy. Surgical technique Introduction Laparoscopic sleeve gastrectomy (LSG) is a new surgical approach for the treatment of morbid obesity. It is a purely restrictive technique whose effectiveness is based on producing early satiety by reducing gastric capacity. Moreover, by eliminating the gastric fundus, it reduces the level of ghrelin, an appetite-stimulating hormone (1 3). LSG often constitutes the restrictive aspect of mixedtechnique procedures. It is combined, for example, with biliopancreatic diversion to form a part of a duodenal switch procedure. Open sleeve gastrectomy was first applied to the M. Ferrer-Márquez : R. Belda-Lozano : M. Ferrer-Ayza Department of Bariatric Surgery, Torrecárdenas Hospital, Almería, Spain M. Ferrer-Márquez (*) : R. Belda-Lozano : M. Ferrer-Ayza Department of General Surgery, Torrecárdenas Hospital, Almería, Spain manuferrer78@hotmail.com treatment of super-obese male patients (those with both a BMI and an age over 55) by Almogy et al. (4) in The introduction of LSG into the duodenal switch procedure was first carried out by Gagner (5) atmountsinaihospitalin New York in 1999, and some years later Regan proposed that it become the first step in gastric bypass surgery as an alternative for decreasing morbidity and mortality in high-risk obese patients (6). While many teams have adopted this technique in recent years and have, in doing so, achieved good short- and medium-term results, there has yet to be an established set of indications for the procedure. It has become common at some institutions to perform SG as the first phase of a twophase process for treating high-risk patients and those with high BMI, with the second procedure carried out once a certain amount of weight loss has been achieved. Though this is done in order to minimize surgical risk, the results obtained by this technique, both in weight loss and solution of comorbidities, have led several authors to propose it as a single procedure (7). The technique has been adopted by a large number of surgeons, influenced heavily by the misconception that it is a simple and easy one (3). In recent years, the number of procedures performed has risen exponentially, reaching 18,098 cases in 2008 (8), which is a figure that has undoubtedly been exceeded in the years since. However, the many points of controversy regarding the procedure create a range of possibilities without consensus: the size of the bougie used as calibrator, the distance from the pylorus to the first line of section, the section shape at the gastroesophageal junction, the necessity and options available for reinforcing the staple line, and the routine use of intraoperative seal testing. All of these are issues that are constantly debated among the most experienced authors (Table 1).

2 OBES SURG (2012) 22: Table 1 Techniques for LSG described in the literature Author No. of patients Bougie gauge Beginning of section (cm) Reinforcement of suture Seal verification Baltasar et al (16) 31 32F 2 Invaginating suture Methylene blue Mognol et al (15) 10 32F 2 3 Electrocoagulation Methylene blue of the suture line Cottam et al (19) F 5 Fibrin ND Roa et al (11) 30 52F 6 Running suture ND Silecchia et al (18) 41 48F 7 8 Peri-Strips Dry Methylene blue Casella et al (36) F 6 8 SeamGuard,Running suture, Methylene blue Bovine pericardium Nocca et al (34) F 10 SeamGuard,Running suture, Methylene blue Diamantis et al (37) 25 Endoscope (29F) 4 SeamGuard Endoscope Bellanger et al (20) F 4 Fibrin ND ND no data Size of Bougie Despite the large expansion in the popularity of LSG in recent years, there is still no consensus as to what size of bougie is the most suitable to calibrate the final tubularization. If we consider it as a restrictive technique, the logical approach would be to reduce gastric volume as much as possible, thus limiting the amount of food ingested and creating a feeling of early satiety. On the other hand, we must take into account that the part of the stomach that is most easily distended is the gastric fundus, which is sectioned and extracted in the course of this technique. This means that small increases in volume result in a significant increase in gastric pressure compared with the intact stomach (9). This argument is used by those authors who support the use of larger-gauge catheters with the aim of avoiding excessively high pressures, thus trying to reduce the rate of leaks. Gagner et al. (10) describe an inverse relation between the size of the bougie and the rate of leaks and advocate the use of catheters between 50 and 60Fr. We must know that 1Fr is equivalent to 0.33 mm. Therefore, 32Fr bougies have a 1.1-cm diameter, those of 36Fr have 1.2 cm, and those of 40Fr have 1.3 cm. Considering that most authors who perform LSG use catheters between 32 and 40Fr, is it possible that there are so many differences among patients treated with these types of catheters when the difference between their sizes is minimal? Some authors believe that the diameter of the catheter is a determining factor in the amount of excess weight lost (EWL). Roa et al. (11), using a 52Fr bougie, report an average of 52.8% EWL after 6 months in patients with 41 BMI. Serra et al., in patients with BMI over 60 and using a 32Fr catheter, obtained a 61% EWL (1). A systematic review by Brethauer et al. (12), which included 36 studies of LSG using catheters from 32 to 60Fr, reports an EWL from 33% to 85%. Weiner et al. compare three groups of patients (one in which no bougie is introduced to calibrate, one using 44Fr catheters, and another using 32Fr catheters) and conclude that, while there are no differences in short-term results, after two years, the results are in favor of the most restrictive groups (13). Parikh et al. retrospectively compare results among patients with 40 and 60Fr catheters, with no differences between groups after 6 and 12 months (14). In addition to the aforementioned discussion, we must bear in mind that, once the bougie is introduced, not all authors perform the section at the same distance. There are some who section adhering to the bougie, while others do so a few millimeters away with the aim of subsequently performing a reinforcing invaginating suture. Moreover, some authors remove the catheter once the section is performed in order to subsequently perform the invaginating suture. It is clear that, if the intention of the catheter is to allow the reproducibility of the technique, all of these factors should be considered in order to obtain a similar volume between different surgical teams for one universal catheter size. Beginning of the Distal Section Another controversial point, which is related to the aforementioned discussion, is the distance from the pylorus at which gastric division begins. The most conservative authors prefer to perform the section at more than 4 cm from the pylorus with the aim of improving gastric emptying and thus decreasing intraluminal pressure, which may hamper its closure in the presence of a leak. In contrast, other authors support sectioning close to the pylorus on the grounds that the technique is purely restrictive, and therefore, greater tubularization will achieve better results and ensure normal gastric emptying and functioning.

3 184 OBES SURG (2012) 22: Mognol et al. (15) and Baltasar et al. (16) begin the division about 2 cm from the pylorus, maintaining that, since it is a purely restrictive technique, it should be more aggressive than when it is part of another technique (such as duodenal switch), which also includes a malabsorptive component. In this case, the gastric remnant is reduced to <50 ml, and ingestion is normal the patient tolerates food in small amounts with normal gastric emptying. Other authors (17 19) begin the resection at 6 7 cm from the pylorus in order to preserve the gastric antrum and theoretically preserve its contractile function, promoting gastric emptying. Because the integrity of the vagal nerve must be preserved in sleeve gastrectomy and therefore no pyloroplasty is performed, it would appear safer to resect the antrum farther from the pylorus. Bellanger et al. (20) begin the section at 3 4 cm from the pylorus, thus decreasing the antral volume while preserving its function. They believe that, in this way, they can reduce the risk of distal stenosis and proximal leaks. Patients who present distal stenosis caused by gastric emptying difficulties are possibly more susceptible to this type of proximal fistula, which occurs at the gastroesophageal junction (3). The main cause of fistulas in this area, as shown by Yehoshua (9), is high intraluminal pressure, combined with low gastric tube compliance. Sánchez-Santos et al., in the results of the Spanish National Registry, report that groups who begin gastrectomy closest to the pylorus obtain better weight-loss results in the follow-up (21). Suture Reinforcement One of the complications most feared by bariatric surgeons after performing LSG is the appearance of a leak, both for the associated morbidity and the difficulty of resolution. The incidence of anastomotic leaks after LSG ranges between 0% and 5.5% for primary surgery and 16 24% in reintervention procedures (3, 20, 22). Most of these leaks appear near the gastroesophageal junction, in the proximal third of the stomach (3). As suggested by Baker, fistulas on the staple line may be related to any number of causes, which may be broadly categorized into mechanical-tissular and ischemic. The root of both types of causes is a level of intraluminal pressure that exceeds tissular resistance and that of the suture line. Typical ischemic fistulas tend to present when the wall-healing process is between the inflammation and fibrotic phases, which usually occurs between 5 and 6 days after surgery. When the cause is mechanical-tissular, fistulas are usually discovered before this period, that is, within the first 2 days after surgery (23). This supports the use of reinforcing materials that, although they do not act on the ischemic cause of fistulas, can reduce the risk of mechanical failure (24). Different technical possibilities have been proposed in order to reduce the risk of leakage at this level: These include suture invagination, biological sealants, and reinforcing materials among others. In recent years, the main suture-reinforcing materials that have appeared on the market are polytetrafluoroethylene (eptfe ), bovine pericardium (Peri-Strips Dry ), small intestine submucosa (Surgisis ), and bioabsorbable polyglycolic acid and trimethylene carbonate (SeamGuard ). The use of SeamGuard (an absorbable polymer membrane) in reinforcing the suture line is described by Consten et al. (25). It is made up of 67% polyglycolic acid synthetic and 33% trimethylene carbonate and is absorbed after around 23 weeks, maintaining its resistance for the first four to five of these. A study of 20 patients treated with SeamGuard concluded that, while the material was successful in reducing the risk of bleeding, it did not significantly reduce leakage. Angrisani et al. (26) practice reinforcement using Peri-Strips Dry and describe their results in 121 patients without presenting postoperative leaks. Fibrin sealants such as Tissucol and Vivostat are also often used to prevent fistulas along the staple line (Fig. 1). Fibrin sealants polymerize on contact with tissue, and in doing so, both bind tissue surfaces together and act as a sealant against leaks. Although its effectiveness in this respect has not been proven, several studies have reported a decrease in the number of leaks when using these products (27, 28). Baltasar et al. (16), as well as our group, protect the staple line with a running seroserous suture that inverts the staples, controls bleeding, and attempts to reduce the number of leaks without increasing the cost of the procedure (Fig. 2). Recently, they describe their technique using an omental patch, together with invagination, in order to reduce the number of leaks and to improve stability and emptying by decreasing the partial torsion that some residual tubes suffer (29). Fig. 1 Placing the reinforcing fibrin

4 OBES SURG (2012) 22: Fig. 2 Reinforcement of staple line by invaginating suture Although more than half of the groups reinforce the suture line in some manner, there are some who prefer not to perform any surgical procedure after the single staple line. To this effect, Kasalicky et al. show their results in 61 patients without reinforcement in the gastric section, and none of whom present any leaks (30). Bellanger et al. (20) show their series of 529 patients presenting no leaks, without using any reinforcing material after the gastric section except the application of fibrin. Dapri et al. (31) compare three techniques in LSG (without reinforcement, with Gore SeamGuard, and with staple line suture). They conclude that there are no differences regarding postoperative leakage in the suture line and that reinforcement by Gore SeamGuard reduces bleeding during gastric section. However, it is possible that the number of patients in the study (75 among the three groups) is not sufficient to find differences, taking into account the known rate of leaks. A recent study concludes that there is no reason to believe that the reduction in the rate of leaks after LSG is due to the suture reinforcement used. The rate of leaks is so low that, in order to obtain statistically significant results between groups, samples close to 10,000 procedures would be needed (32). Fig. 3 Proximal section away from the gastroesophageal junction present, by the posterior gastric artery. The arterial supply of the esophagus is segmental. Complete dissection of the fundus requires division of the short gastric vessels, of the posterior gastric artery, and of the phrenic branches when present. A critical area of vascularization may occur laterally, just at the esophagogastric junction at the angle of His (Fig. 4). They describe a resection line avoiding the critical area by leaving 1 2 cm of gastric remnant just at the gastroesophageal junction to solve the problem. They adopted this technique in 26 patients, no leaks occurred, and the residual capacity of the gastric stump remained unchanged. However, our group is not in favor of this maneuver as one of the leaks in our series presented exactly at the distal end of this remnant as a result of an ischemic problem. Nocca et al. show particular caution at this point in those patients who previously underwent surgery by adjustable gastric band due to the fragility of gastric tissue secondary to fibrosis after contact with the silicone band (35). Bellanger et al. (20) strongly believe in two basic principles for minimizing the rate of leaks: The first and most important is to avoid creating a stenosis at the level of the angular incisure, and the second is to avoid mechanical section too close to the esophagus in the area of the cardia. Proximal Section of the Stomach As mentioned previously, one of the theories possibly the best-supported of proximal fistula formation along the gastroesophageal junction is the vascular theory, which is associated with increased intragastric pressure. Based on this idea, many authors suggest the performance of a proximal section (as in Fig. 3) with special care as far as possible from the gastroesophageal junction (33). As Basso et al. explain (34), the cardias (distal esophagus and esophagogastric junction) are supplied in the right and anterior side by branches of the left gastric artery and left inferior phrenic artery. The posterior left side is vascularized mainly by fundic branches of the splenic artery and, if Fig. 4 Critical area of vascularization

5 186 OBES SURG (2012) 22: Therefore, there seems to be a consensus on the caution with which to perform the last section at the gastroesophageal junction, thereby avoiding contact with the esophagus and minimizing as much as possible the occurrence of complications at this level (Fig. 3). Seal Verification Once the gastric section is completed, most authors perform various seal tests to ensure the absence of intraoperative leaks that require immediate repair. The methylene blue test was originally described to diagnose fistulas after gastrectomy (36); it is one of the most widely used tests in bariatric surgery and consists of the oral administration of methylene blue and observation for any intraoperative output through the gastric tube. Other authors use the air test, in which they fill the abdominal cavity with serum and instill air through the catheter to check for bubbles that could indicate the existence of a leak. These methods are simple, accessible, and inexpensive and, in case of negative results, reassure the surgeon before closure. However, we must know that these methods are only useful when they give positive results as, when they are negative, they do not exclude the presence of a fistula (37). Recently, Diamantis et al. show their results from performing intraoperative endoscopy, with which they check for the absence of complications after the section. Once the gastric tube is inserted, the endoscope insufflates a minimal amount of air in order to inspect the staple line from the gastric interior in search of points of bleeding or suspected disruption in the staple line. At the same time, laparoscopic vision confirms the absence of bubbles as if it were an air test (38). Similarly, Frezza et al. use a 29F endoscope that serves, firstly, as a bougie to perform the section and also to test, at the end of the procedure, the integrity of the gastric tube and seal from an internal viewpoint (39). Conclusion Although LSG has been gaining popularity over the last few years and the number of bariatric surgery units that offer it is increasing, there is not yet a standard technique for this procedure. Heterogeneity mainly affects the size of the bougie, the beginning of the section, and reinforcement of the suture; this is, perhaps, why we find such disparate results in the literature. The solution may lie in finding a suitable size at which the pressure of the tube is not excessive and the restriction is sufficient for obtaining good weight-loss results without increasing the risk of complications. It would be ideal to standardize the surgical technique with a view of performing systematic reviews, long-term multicenter studies, and consensus conferences. It is very important that we attempt to standardize this surgical technique as much as possible. In this way, we can ensure that the great majority of teams work using similar methods, with a view of carrying out systematic reviews, long-term multicenter studies, and consensus conferences. Acknowledgements We would like to thank Dr. Aniceto Baltasar and Manuel Miras for their help. Conflict of Interest The authors (Manuel Ferrer-Márquez, Ricardo Belda-Lozano, and Manuel Ferrer-Ayza) declare that they have no conflict of interest. References 1. Serra C, Pérez N, Bou R, et al. Laparoscopic sleeve gastrectomy. A bariatric procedure with multiple indications. Cir Esp. 2006;79 (5): Marceau P, Cabanac M, Frankham PC, et al. Accelerated satiation after duodenal switch. Surg Obes Relat Dis. 2005;1(4): Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20(9): Almogy G, Crookes PF, Anthone GJ. 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