A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY IV: Sleeve as a Revisional Surgery injuries during LSG procedures.4 In addition, excessive staple-line usage often causes staple-line crossing, which may lead to leak in this thick tissue LSG procedures.5 Second, stomach tissue is thick even if a band slippage is not present; therefore, staple height lengths have to be larger.6 I have found that if you use blue, you might consider upstaging to green near the capsule and around the left crux. I use Tristaple (Covidien, Mansfield, Massachusetts) because of the steelreinforced anvil and varying staple heights, which I find helps with staple formation without excessive bleeding. I use purple Tristaples all the way up. Third, I have found that when doing any revision, the gastroesophageal junction must be clearly visible because it is a constant landmark that helps guide your sleeve, avoiding excessive tissue at the left crux. If the GE junction is not visible, you can have excessive fundal tissue, which can cause a "dog ear" and weight regain down the line.4 Lastly, I use a 40Fr bougie, and, because it is a revision, I oversew the sleeve, completely imbricating the staple line. revisional laparoscopic gastric bypass after failed adjustable gastric banding and after vertical banded gastroplasty: experience with 107 cases and subgroup analysis. Surg Endosc. 2013;27:558–564. REFERENCES 1. 2. 3. 4. 5. 6. Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery. 2009:145:106–113. Victorzon M. Revisional bariatric surgery by conversion to gastric bypass or sleeve—good short-term outcomes at higher risks. Obes Surg. 2012;22:29–33. Vemulapalli P. Author's personal data. Schwartz RW, Strodel WE, Simpson WS, Griffen WO, Jr. Gastric bypass revision: 205 lessons learned from 920 cases. Surgery. 1988;104:806–812. Hallowell PT, Stellato TA, Yao DA, et al. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg. 2009;197:391–396. Apers JA, Wens C, van Vlodrop V, et al. Perioperative outcomes of ADDITIONAL RESOURCES 1. 2. 3. 8 Neff K, Olbers T, le Roux C. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med. 2013;11:8. Mor A, Keenan E, Portenier D, Torquati A. Case-matched analysis comparing outcomes of revisional versus primary laparoscopic Rouxen-Y gastric bypass. Surg Endosc. 2013;27:548–552. Parikh M, Issa R, McCrillis A, et al. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg. 2013; 257:231–237. Video Feature www.metabo licsurger y.tv View a video of Dr. Vemulapalli performing an LSG procedure with hiatal hernia repair. Scan here for the exclusive video May 2013 • Supplement A • Bariatric Times A17