I read with interest the new study “Assessment of Sleeve Gastrectomy Surgical Technique: First Look at 30-Day Outcomes Based on the MBSAQIP Database” published by my colleague Dr. Chaar in JACS current issue. The author compares different techniques in staple line reinforcement in sleeve gastrectomy cases collected in the MBSAQIP database. A total of 81521 primary sleeve gastrectomies were retrospectively analyzed. The study primary outcomes were bleeding defined as any event requiring blood transfusion and staple line leak. The different techniques involving staple line reinforcement included the use of absorbable membranes like bovine pericardial strips to buttress the staple lines, staple line oversewing, or both buttressing and oversewing.

The authors conclude that sleeve gastrectomy leak rate is not affected by staple line reinforcement technique. On the other hand, the study shows that staple line buttressing with or without oversewing, but not oversewing alone, decrease postoperative bleeding.

At Houston Weight Loss Surgery Center, I routinely use staple line reinforcement using absorbable buttressing membranes to decrease postoperative bleeding. I avoid oversewing the staple line as it leads to staple line twisting and narrowing. I agree with study results that staple line reinforcement does not decrease leak rate. I strongly believe that narrowing the incisura angularis leads to partial obstruction. Gastric lumen obstruction at the incisura angularis increases intra-gastric pressure potentially contributing to staple line failure at the level of the angle of His. In order to preserve the natural angulation of the stomach at the incisura angularis, we avoid resecting the stomach in that area over a bougie. Rather, we fire the first two to three stapler loads without a bougie in place then insert a 40 F bougie and continue sleeve resection.