Bariatric Times

Spotlight on Technology December 2014

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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C2 Bariatric Times [DECEMBER 2014, SUPPLEMENT C] SPOTLIGHT ON TECHNOLOGY reinforced staple lines. This is very apparent when teaching those new to these procedures as it minimizes the handling of virgin tissues. When did you start using GORE ® SEAMGUARD ® Staple Line Reinforcement? What instrumentation do you use with the product? A: Since around 2004, I have been using GORE ® SEAMGUARD ® Bioabsorbable Staple Line Reinforcement. Regardless of stapler type, the use of GORE ® SEAMGUARD ® Reinforcement increases the strength of the staple line and is, therefore, valuable for any stapler. Prior to using GORE ® SEAMGUARD ® Reinforcement, what method did you use to reinforce the staple line? A: I used reinforcement with nonabsorbable bovine pericardial strips (Peri-Strips Dry, Baxter Healthcare, St. Paul, Minnesota, United States). Why did you switch to using GORE ® SEAMGUARD ® Reinforcement? A: I chose to switch my reinforcement method for several reasons. First, Peri-Strips Dry—a bovine pericardium material—was not uniform in thickness so the staple fires were uneven. Also, at that time the Peri-Strips Dry version was not bioabsorbable or remodelable unlike GORE ® SEAMGUARD ® Reinforcement which absorbs within 6 to 7 months, reducing the likelihood of long-term complications, such as bowel obstruction. I also found that the delivery mechanism for the Peri-strips Dry product, which involved the application of a gel substance to the strip was unreliable, specifically when teaching residents. It would frequently cause the strip to fall off of the stapler if one touched adjacent tissue prior to putting it in the proper place. When considering switching products, I found that the GORE ® SEAMGUARD ® Reinforcement strings helped to better hold the strips in place in these circumstances. Approximately how many cases in a year are performed at your clinic using GORE ® SEAMGUARD ® Reinforcement? A: GORE ® SEAMGUARD ® Reinforcement is used in Roux-en-Y gastric bypass (RYGB) procedures, LSG, and revision operations. I use the Echelon Flex ™ Powered Endopath ® Stapler (Ethicon, Cincinnati, Ohio, Unted States) in all three types of operations. For the LSG, I use two black loads and gold loads on the remainder of the operation and I reinforce the entire staple line with GORE ® SEAMGUARD ® Reinforcement. In RYGB cases, I use two black loads to close the gastrotomy and gold loads on the pouch. The type and amount of loads used in revision procedures may vary depending on thickness. The approximate yearly breakdown of these procedures is as follows: 100 RYGB and 1300 to 1400 LSG/revisions. What have your complication rates for leaks and bleeding been since using GORE ® SEAMGUARD ® Reinforcement? A: Since using GORE ® SEAMGUARD ® Reinforcement, we have experienced leaks in less than 1 out of 2,000 cases and bleeding in less than 1 out of 1,000 cases. As a high-volume surgeon, can you describe how the use of GORE ® SEAMGUARD ® Reinforcement has changed your practice? A: As a practice that performs approximately 1,500 stapled procedures per year, low complication rates are paramount. It would be almost physically impossible to do this volume otherwise. Considering a leak rate of two percent, this would mean that there are 30 leaks per year. If someone comes in with a leak, we treat it as an emergent condition, which is very disruptive to the daily functioning of the practice. Usually, it requires me to travel to another center across town to re-operate and treat the leak. This requires me to reschedule patients I was scheduled to see, which may be up to 15 cases in one day. This lost time also does not allow time for new patient consults and many elective cases would be cancelled. Patient satisfaction drops when there are delays, which leads directly to deterioration in our main referral source— previous patients that were pleased with their experience and outcome. This leads to fewer new patients, which would translate to lower volume. It is important to treat leaks immediately because the longer you wait, the sicker the patient gets, which may lead to a worse outcome. The event of a leak creates a domino effect that slows down functioning of the practice and impacts patient satisfaction. Also, the extra time and energy spent on treating complications may cause surgeon fatigue. Tired physicians do not have the same demeanor as well-rested physicians. Spending less time and energy fixing complications allows me more energy to focus on new and existing cases that need attention. As a referral center for surrounding areas, we care for patients with complications. Of the last 14 leaks we have accepted in transfer, 12 were self-inflicted from the patient stressing the staple line too early in the healing process (e.g., eating solids too early). This was the case with one patient who experienced this before Postoperative Day 21. We have a very real percentage of patients that pay for care out of pocket. We find that this patient population typically considers complications unacceptable. Knowing that we can count the number of leaks experienced at our practice on less than one hand allows us to deliver care to these patients with confidence.

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