Bariatric Times - Supplement A - Covidien - (Page 18)

THE 2007 INTERNATIONAL CONSENSUS SUMMIT ON SLEEVE GASTRECTOMY Using larger staples provides adequate thick tissue compression; however, this may be associated with more bleeding. intraluminal hemorrhage. Although much can be made of the varying degrees of thickness of the stomach, the reality is the difference is minimal and well within manufacturers’ suggested usage that green loads can be used on the entire staple line of the stomach. There are several important technical points to be made. The first is that hemorrhage may occur because of the “bunching” at the intersections (or “crotch”) of the previously applied staple line. If you bring your stapler load across another staple line, it makes it very difficult for the stapler to fire. The stapler blade “locks” when it crosses the metallic staples. When the surgeon applies excess force to overcome this resistance, the tissue may tear and this can result in hemorrhage. Consideration should therefore be given to oversewing the junctions of staple lines; however, there is little evidence that imbricating the entire staple line is necessary. Another important technical tip is that the surgeon should leave a little shoulder or neck of gastric tissue at the angle of His. This actually makes sense if you think about the stapler mechanics. If there is migration of the esophagus on to the staple line, the esophagus is much thinner than the gastric tissue. The amount of force you actually have to apply in grams per square centimeter to compress the tissue is different. This is a potential spot where the tissue will tear because you are applying much force on the stomach and you don’t need the same force on the esophagus. The result is the staples are not applied evenly and bleeding can occur through the staple line. Using larger staples provides adequate thick tissue compression; however, this may be associated with more bleeding. Another important point is that the bleeding may not be immediate. As noted above, the stapler technology compresses and then relaxes; therefore, you actually can get a little bit of bleeding after a few minutes. We, and others, have started using buttress materials on a regular basis to prevent bleeding. One of our laparoscopic fellows, Esther Constan, published a small prospective study,1 of 10 patients with Gore Seamguard® buttress and 10 patients without for the sleeve gastrectomy part of the duodenal switch operation. We analyzed this data for intraoperative and postoperative leaks and complications, including hemorrhage. The average number of Seamguard® applications varied from 4 to 8. There was no difference in operating room time. There were no staple-line leaks in the groups, and three complications in the control group, but this was not significant. There was definitely decreased bleeding intraoperatively in the buttress group. There were no adverse events noted from bioabsorbable Seamguard®. REFERENCES 1. Consten ECJ, Gagner M, Pomp A, et al. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg. 2004;14(10);1360–1366. KEY POINTS • Prevention is the best treatment for hemorrhage. • Hemorrhage after sleeve gastrectomy is intraperitoneal and not intraluminal. • Stapler loads should not fire across the gastroesophageal junction. • There is good evidence that buttress materials decrease bleeding after sleeve gastrectomy. 18 Bariatric Times [ J U N E 2008, SUPPLEMENT A]

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Bariatric Times - Supplement A - Covidien Contents Laparoscopic Sleeve Gastrectomy: From Magenstrasse And Mill To Sleeve Sleeve Gastrectomy Provides Resoultion of Type-2 Diabetes Without Duodenal Exclusion The Relationship Bewtween The Resected Remnant And Weight Loss Laparoscopic Sleeve Gastrectomy: Results After Two And Five Years Laparoscopic Sleeve Gastrectomy As An Initial Weight Loss Procedure For High-Risk Patients With Morbid Obesity Three-Year Results Of Laparoscopic Sleeve Gastrectomy In The Treatment Of Morbid Obesity In Korea Laparoscopic Sleeve Gastrectomy: Nutritional Concerns And PostOperative Dietary Care Laparoscopic Sleeve Gastrectomy: Prevention And Treatment Of Bleeding Prevention And Treatment Of Gerd/Hiatal Hernia And Stenosis Associated With Sleeve Gastrectomy Laparoscopic Revisions Of Sleeve Gastrectomy Survey Results

Bariatric Times - Supplement A - Covidien

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