Bariatric Times - June 2008 - (Page 18)

18 Surgical Perspective Bariatric Times • June 2008 have shown that the learning curve for LRYGB is between 50 and 75 cases.5,6 Inexperienced surgeons may be unfamiliar with the anatomy on laparoscopic view or may have limited experience with endostaplers, leading to incorrect use or inappropriate sizing of staple loads. PREVENTION Various technical modifications have been described to decrease the incidence of postoperative bleeding, mainly directed at the staple-line sites and include appropriate choice of staple size/height, oversewing staple lines, performing handsewn anastomoses, application of pressure via stapling device prior to firing, staple-line reinforcements, buttressing, and use of hemostatic agents on staple lines. Most bleeding following LRYGB is from areas along the staple lines; therefore, it is of utmost importance to select the appropriate staple size/height that will allow for hemostasis while avoiding tissue necrosis. Staple loads are referred to by color based on the size and height of staples. Table 1 shows stapler load characteristics and recommended uses. Some authors recommend oversewing all staple lines and/or performing hand-sewn anastomoses4 as a means of decreasing the incidence of postoperative bleeding. Although these techniques may decrease the number of patients with postoperative bleeding, they also significantly increase the complexity of the case and time required in the operating room. There is also a theoretical risk of narrowing lumens in the case of oversewing. There are several commercially available staple-line reinforcements and hemostatic agents that have been developed to decrease MOST BLEEDING FOLLOWING LRYGB is from areas along the staple lines; therefore, it is of utmost importance to SELECT THE APPROPRIATE STAPLE SIZE/HEIGHT that will allow for hemostasis while avoiding tissue necrosis. intraoperative and postoperative bleeding.8 Staple-line reinforcement products include Peri-Strips™ (BioVascular Inc., Saint Paul, Minnesota), which are composed of bovine pericardium, Peri-Strips Dry with Veritas™ (Synovis Surgical, Saint Paul, Minnesota), composed of a collagen matrix, and Seamguard™ (W.L. Gore & Associates Inc., Flagstaff, Arizona), which is composed of either ePTFE (first generation), or absorbable maxon (second generation). In a randomized prospective trial, staple-line reinforcement was shown to reduce staple-site bleeding, decrease blood loss, and possibly reduce the incidence of gastrointestinal hemorrhage.9 Other hemostatic agents, such as fibrin sealant placed around the anastomosis, may allow surgeons to achieve better hemostasis.10 Tiseel™ (Baxter, Westlake Village, California), approved by the FDA in 1998, has been used clinically as an adjunct to hemostasis during surgery.10 Although there is currently no such product available, a hemostatic gel that could be placed directly onto the staple load11 could potentially decrease the incidence of postoperative bleeding. DIAGNOSIS The most challenging aspect of diagnosing acute hemorrhage following Roux-en-Y gastric bypass is differentiating between intraluminal and extraluminal bleeding sources. Most authors agree that there is little or no role for localization studies such as tagged red cell scans.1,2,4 Computed tomography (CT) scan may prove helpful, especially in the case of bleeding into the excluded remnant stomach. Spaw, et al.,3 support the use of arteriography to localize bleeding as a diagnostic maneuver, but assert that embolization is contraindicated due to the hazard of devascularizing fresh staple lines. The clinical picture, along with the timing and color of the blood (hematemesis, melena, blood per rectum) may also help clarify the bleeding site. Clinical signs of hypotension, tachycardia, bright red hemorrhage, http://www.bariatricadvantage.com http://www.kappsurgical.com http://www.kappsurgical.com

Table of Contents Feed for the Digital Edition of Bariatric Times - June 2008

Bariatric Times - June 2008 Endoluminal Treatment Options for Morbid Obesity: Devices and Techniques for Natural Orifice Approaches The Multidisciplinary Approach to Weight Loss: Defining the Roles of the Necessary Providers Acute Bleeding after Gastric Bypass Editorial Message Contents ASMBS: 25 Years Editorial Board Surgical Site Infection In The Morbidly Obese Patient: A Review Consultant's Corner The Link Between Sleep Loss and Obesity: Understanding the Mechanisms Responsible for Weight Gain with Sleep Deprivation Volume Matters Journal Watch Advertiser Index

Bariatric Times - June 2008

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