Staple line Reinforcement, Distance From Antrum and Bougie Size: A New Study From MBSAQIP

A fascinating new study analyzed 190,000 gastric sleeve cases performed between 2012 and 2014 at accredited bariatric surgery centers by MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program). The study was presented at the 2016 annual meeting of the American Surgical Association. 80% of the 1634 surgeons who performed these gastric sleeve surgeries used staple line reinforcement. A practice associated with decreased bleeding but a significantly higher leak rate according to this analysis. The study does not expand on the type of reinforcement used. Therefore, one cannot conclude if all types of reinforcement are associated with increased leak rate. This may be a major weakness associated with this high power study as over-suturing the staple line with or without imbrication may narrow the incisura angle and weaken the staples increasing the leak rate. Reinforcement material like Seamguard and bovine pericardium is conceptually and mechanistically different from suturing the staple line. Hence, it would be very interesting to break down the staple line leak cases into types of reinforcement to further understand this serious complication and better prevent it in the future.

The analysis further demonstrates that contrary to previous recommendations, weight loss was greatest in gastric sleeve cases with a bougie size of 40 French or more and a preserved antrum. Indeed, weight loss increased incrementally as the distance from the pylorus increased from 4 to greater than 6 cm. In other words, avoiding stomach “mutilation” is a good practice associated with improved weight loss. Gastric sleeve surgery is a metabolic procedure. Weight loss and blood sugar improvement result from altering gastric motility and gastric emptying patterns. These physiologic alterations are most likely related to gastric fundus resection. Reducing the gastric sleeve volume by itself does not result in better weight loss. Weight loss is in fact not proportional to gastric sleeve volume reduction. As this study alludes to, weight loss is improved with antral preservation. One would conclude that the worst gastric sleeve is that which destroys the antrum by using a small bougie size and starting the resection very close to the pylorus. The antrum is the gastric pump and by preserving this vital part of the stomach gastric emptying is improved. In my opinion, the best gastric sleeve surgery is the one that completely resects the ballooning part of the stomach while preserving the gastric antrum. A better approach to gastric sleeve resection is gastric fundus invagination, GFI. GFI is a procedure I developed based on these concepts and observations. It prevents gastric fundus relaxation and meal accommodation leading to increased gastric emptying. GFI has the advantage of being reversible, safe (short staple line), and a non “mutilating” procedure. GFI preserves gastric fundus tissue that secretes Leptin a hormone that contributes to increased satiety and may lead to better long-term weight loss than gastric sleeve surgery. Additional studies are needed to elucidate the role of gastric Leptin in weight loss surgery and its effect on long-term weight loss. If Leptin is indeed associated with better or more balanced weight loss then GFI may be a better option than gastric sleeve resection.