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Surgical Strategies That May Decrease Leak After Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis of 9991 Cases

Parikh, Manish MD*; Issa, Reda BA*; McCrillis, Aileen MLIS; Saunders, John K MD*; Ude-Welcome, Aku MD*; Gagner, Michel MD

doi: 10.1097/SLA.0b013e31826cc714

Objective: To conduct a systematic review to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG).

Background: LSG is growing in popularity as a primary bariatric procedure. Technical aspects of LSG including bougie size remain controversial.

Methods: Our systematic review yielded 112 studies encompassing 9991 LSG patients. A general estimating equation (GEE) model was used to calculate the odds ratio (OR) for leak based on bougie size, distance from the pylorus, and use of buttressing on the staple line. Baseline characteristics, including age and body mass index (BMI), were included. A linear repeated measures regression model compared excess weight loss (%EWL) between bougie sizes.

Results: A total of 198 leaks in 8922 patients (2.2%) were identified. The GEE model revealed that the risk of leak decreased with bougie ≥40 Fr (OR = 0.53, 95% CI = [0.37–0.77]; P = 0.0009). Buttressing did not impact leak. There was no difference in %EWL between bougie <40 Fr and bougie ≥40 Fr up to 36 months (mean: 70.1% EWL; P = 0.273). Distance from the pylorus did not affect leak or %EWL.

Conclusions: Utilizing bougie ≥40 Fr may decrease leak without impacting %EWL up to 3 years. Distance from the pylorus does not impact leak or weight loss. Buttressing does not seem to impact leak; however, if surgeons desire to buttress, bioabsorbable material is the most common type used. Longer-term studies are needed to definitively determine the effect of bougie size on weight loss after LSG.

Our meta-analysis of 9991 laparoscopic sleeve gastrectomy cases reveals that utilizing bougie ≥40 Fr may decrease leak without significantly impacting weight loss up to 3 years. Distance from the pylorus does not impact leak or weight loss. Staple-line buttressing does not seem to impact leak rate.

*Department of Surgery, NYU School of Medicine, New York, NY, and Bellevue Center for Obesity and Weight Management, Bellevue Hospital Center, New York, NY

NYU Health Sciences Libraries, NYU School of Medicine, New York, NY

Department of Surgery, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, and Clinique Michel Gagner, Inc., Montreal, Quebec, Canada.

Reprints: Manish Parikh, MD, Department of Surgery, NYU Medical Center, Bariatric and Minimally Invasive Surgery, Bellevue Hospital Center, 550 First Avenue, NBV 15 South 7, New York, NY 10016. E-mail:

Disclosure: M.P. was supported by grant number K12HS019473 from the Agency for Healthcare Research and Quality. The role of the funding was for data analysis only. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. M.G. has the following disclosures: EMS, equity and consultant; Covidien, consultant, honoraria; Ethicon, consultant, honoraria; Gore, consultant, honoraria; Olympus, consultant, honoraria; Synovis, consultant; Karl Storz, consultant, honoraria; Cine-Med, honoraria; Bariatric Times, honoraria. None of the remaining authors have financial disclosures.

© 2013 Lippincott Williams & Wilkins, Inc.