Advertisement

Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

Published:August 10, 2019DOI:https://doi.org/10.1016/j.soard.2019.07.017

      Highlights

      • LSG is a safe procedure with a low morbidity and mortality
      • LSG leak rate was 0.6% in 175353 patients from 2015 to 2016
      • Bleed increases all complications, readmission, reoperation and mortality at 30 days
      • Staple line reinforcement and oversewing are the greatest protective factors for bleeding following LSG
      • Therapeutic anticoagulation is the greatest predictor of bleeding after LSG

      Abstract

      Background

      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.

      Objectives

      The purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG.

      Setting

      The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.

      Methods

      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 bleed.

      Results

      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 significant.

      Conclusion

      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.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Gagner M.
        • Buchwald J.N.
        Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review.
        Surg Obes Relat Dis. 2014; 10: 713-723
        • Kumar S.B.
        • Hamilton B.C.
        • Wood S.G.
        • Rogers S.J.
        • Carter J.T.
        • Lin M.Y.
        Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry.
        Surg Obes Relat Dis. 2018; 14: 264-269
        • Ponce J.
        • Demaria E.J.
        • Nguyen N.T.
        • Hutter M.
        • Sudan R.
        • Morton J.M.
        American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States.
        Surg Obes Relat Dis. 2016; 12: 1637-1639
        • Angrisani L.
        • Santonicola A.
        • Iovino P.
        • Formisano G.
        • Buchwald H.
        • Scopinaro N.
        Bariatric surgery worldwide 2013.
        Obes Surg. 2015; 25: 1822-1832
        • Rebibo L.
        • Dhahri A.
        • Chati R.
        • Cosse C.
        • Huet E.
        • Regimbeau J.-M.
        Effectiveness of fibrin sealant application on the development of staple line complications after sleeve gastrectomy.
        Ann Surg. 2018; 268: 762-768
        • Moon R.C.
        • Shah N.
        • Teixeira A.F.
        • Jawad M.A.
        Management of staple line leaks following sleeve gastrectomy.
        Surg Obes Relat Dis. 2015; 11: 54-59
        • Wang H.
        • Lu J.
        • Feng J.
        • Wang Z.
        Staple line oversewing during laparoscopic sleeve gastrectomy.
        Ann R Surg Engl. 2017; 99: 509-514
        • Chakravartty S.
        • Sarma D.R.
        • Chang A.
        • Patel A.G.
        Staple line bleeding in sleeve gastrectomy — a simple and cost-effective solution.
        Obes Surg. 2016; 26: 1422-1428
        • Demeusy A.
        • Sill A.
        • Averbach A.
        Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy : an analysis of MBSAQIP data, 2015 – 2016 PUF.
        Surg Obes Relat Dis. 2018; 14: 1454-1461
        • Saleh M.
        • Cheruvu M.S.
        • Moorthy K.
        • Ahmed A.R.
        Laparoscopic sleeve gastrectomy using a synthetic bioabsorbable staple line reinforcement material: post-operative complications and 6 year outcomes.
        Ann Med Surg. 2016; 10: 83-87
        • Ugo S.D.
        • D M
        • Gentileschi P.
        • et al.
        Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: a multicenter study.
        Surg Obes Relat Dis. 2014; 10: 450-454
        • Aurora A.R.
        • Khaitan L.
        • Saber A.A.
        Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.
        Surg Endosc Other Interv Tech. 2012; 26: 1509-1515
        • Shikora S.A.
        • Mahoney C.B.
        Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis.
        Obes Surg. 2015; 25: 1133-1141
        • Dapri G.
        • Cadière G.B.
        • Himpens J.
        Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques.
        Obes Surg. 2010; 20: 462-467
        • Baker R.S.
        • Foote J.
        • Kemmeter P.
        • Brady R.
        • Vroegop T.
        • Serveld M.
        The science of stapling and leaks.
        Obes Surg. 2004; 14: 1290-1298
        • Frattini F.
        • Delpini R.
        • Inversini D.
        • Pappalardo V.
        • Rausei S.
        • Carcano G.
        Gastric leaks after sleeve gastrectomy: focus on pathogenetic factors.
        Surg Technol Int. 2017; 31: 123-126
        • Al Hajj G.N.
        • Haddad J.
        Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs oversewing.
        Obes Surg. 2013; 23: 1915-1921
        • Al-Kurd A.
        • Grinbaum R.
        • Abubeih A.
        • et al.
        Not all leaks are created equal: a comparison between leaks after sleeve gastrectomy and Roux-en-Y gastric bypass.
        Obes Surg. 2018; 28: 3775-3782
        • Berger E.R.
        • Clements R.H.
        • Morton J.M.
        • et al.
        The impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP).
        Ann Surg. 2016; 264: 464-471