A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/130204
4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY of hiatal hernias 3. Stapler use and cartridge choice 4. Bougie size 5. Use of staple line reinforcement/oversew of staple line 6. Use of energy/vessel coagulation. Despite the relatively straightforward topics, the amount of variability of opinion among the luncheon participants was significant. The topics that had the greatest dissent of opinion were the use of staple reinforcement, the choice of staple cartridges used during the procedure, and the approach to hiatal dissection and repair of hiatal hernia. Participants were strongly divided about repairing hernias, meticulously dissecting the hiatus, and using other than "thick" tissue staple loads for the VSG. AUTHOR'S RECOMMENDATIONS In my 12-year experience of performing VSG (more than 2,500 cases), I have tried many different techniques and modified my approach to this procedure many times. I strongly believe that the following technical issues are paramount to obtaining not only the lowest incidence of complications, but also consistent, acceptable long-term weight loss outcomes: Mobilization. Mobilization of the greater curvature and posterior stomach prior to gastric stapling is important as it prevents formation of an hour-glass stomach (residual posterior gastric volume in the proximal stomach) as well as preventing "corkscrewing" of the gastric staple line. Dissection of the hiatus and repair of hiatal hernias. Thorough dissection of the hiatus and gastroesophageal junction, including the perigastric fat pad is critical. This is essential not only to identify subtle hiatal hernias, but also to definitively identify the delineation of the esophagus from the stomach to avoid stapling the esophagus and leaving a minimal cardiac "cuff." All hiatal hernias should be repaired no matter how subtle. Failing to do so will almost certainly induce post-sleeve reflux. The repair should involve mobilization of the distal 6 to 8cm of the esophagus and approximating the hiatus posteriorly. Staple use and cartridge choice. When stapling the stomach, I always use the largest (leg-length) and heaviest (wire-gauge) stapler cartridge available, as the distal stomach and antrum present a true technical challenge to any staple platform. Minimizing leak rate and bleeding are clearly dependant on the correct staple selection. Bougie size. Bougie size should be the smallest possible to maximize the extent of gastric resection. My personal recommendation is 32 French. Antral resection should be initiated 2 to 4cm from the pylorus, and the line of resection should be parallel to the lesser curvature. As the staple line progresses proximally, the bougie should be withdrawn to stay approximately 1cm distal to the end of the staple line. This prevents "twisting" of the gastric staple line. Staple line reinforcement. Staple line reinforcement has clearly been shown to reduce staple line bleeding1–4 and may reduce the incidence of leaks. I never oversew the proximal staple line as I feel this increases the potential for tissue ischemia and leak if the staple line is made in the correct location (<1cm from the GE junction). Oversewing the staple line in the body of the stomach increases the potential for bleeding and hematoma formation, and, therefore, I also avoid this. Occasionally (~20%), the antral staple line needs to be oversewn due to "cracking" of the serosa and submucosa in an individual with an extremely thick stomach. This should never be a problem as there is significantly more tissue than there is proximally and the blood supply of the distal stomach is significantly better. Choice of energy device. The choice of the energy device should be based on its ability to coagulate small and medium vessels and tendency to KEY POINTS • The ISCCG-4 discussed technical options and alternatives in six specific areas: • Mobilization of the greater curvature – before or after stapling • Dissection of the hiatus and repair of hiatal hernias • Stapler use and cartridge choice • Bougie size • Use of staple line reinforcement/ oversew of staple line • Use of energy/vessel coagulation • The topics that had the greatest dissent of opinion were the use of staple reinforcement, the choice of staple cartridges used during the procedure and the approach to hiatal dissection and repair of hiatal hernia. • There still exists significant disparity in how the VSG is performed among surgeons. minimize thermal spread and adjacent tissue damage. My preference is to avoid ultrasonic-based devices as the operating temperature is much higher and the active blade can injure adjacent tissue, especially near the spleen and hiatus. Bipolar energy platforms provide excellent coagulation with very minimal collateral tissue damage. In addition, only the tissue within the jaw is coagulated, minimizing the potential for adjacent inadvertent tissue injury. CONCLUSION In summary, there still exists significant disparity in how the VSG is performed among surgeons. This has narrowed over the course of the past four years, mostly due to meetings and gatherings, such as the ICSSG where experience between bariatric surgeons around the world is shared, discussed, and debated with the goal of improving outcomes and minimizing adverse events. REFERENCES 1. Daskalakis M, Berdan Y, Theodoridou S, et al. Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. May 2013 • Supplement A • Bariatric Times A25