Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication
associated with significant morbidity and a drastic increase in healthcare resources.
Multiple strategies have been developed to minimize bleeding, including varying bougie
size, line reinforcement, and intra-operative tranexamic acid. These techniques, however,
have been implemented without a clear understanding of the pre-, intra-, and postoperative
predictors of bleeding in patients undergoing SG.
The purpose of this study was to examine predictors and outcomes associated with postoperative
bleeding in patients undergoing LSG.
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.
We identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement
patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include
identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our
secondary outcomes of interest include characterizing overall complication rates in
LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was
performed using Χ2 tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model
was then developed to determine predictive factors for development of postoperative
A total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients
were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index
of 45.2 kg/m2 ± standard deviation of 7.9 kg/m2. A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated
with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative
time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean
pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of
patients while 22.4% were oversewn. Bleeds were associated with a statistically significant
increase in all complications, readmission, reoperation, and mortality rates at 30
days. The following statistically significant independent predictors of bleed after
LSG were identified using multivariable logistic regression analysis: bougie size,
age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation,
diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement,
staple-line oversewing, and higher body mass index were found to be protective for
bleed after adjusting for confounders and interactions. An increase in pylorus distance
did show a signal toward a protective effect; however, this was not statistically
Bleeding after LSG is associated with increased complications, readmission and reoperation
rates, and mortality at 30 days. Staple-line reinforcement techniques independently
predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques
may therefore have an important role in reducing morbidity and mortality for patients
who undergo LSG.