Surgical techniques do matter in laproscopic sleeve gastrectomy: JAMA

In any surgical procedure, various aspects of technique may affect the patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes. The study of outcomes has become essential for guiding quality-of-care assessments. Researchers of Brigham and Women's Hospital in Boston assessed surgeons' varying technical approaches in dissecting the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing.

It was a comparative cohort review study of video operations performed by 30 different surgeons on 6915 patients with morbid obesity. Researchers used two complementary sources of data from the Michigan Bariatric Surgery Collaborative to obtain data on patient characteristics, operations, and subsequent outcomes. They collected intraoperative videos of laparoscopic sleeve gastrectomies between 2015 and 2016 that were voluntarily submitted by surgeons, each surgeon usually submitting about one or two videos. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients. The major outcome assessed was the rate of postoperative hemorrhage and staple line leak after 30 days of surgery. Researchers also assessed the percentage of total weight lost and reflux severity 1 year after the surgery.

Key findings of the study were;

♦After assessing the videos the researchers found higher ratings for complete mobilization of fundus were tied to a significant decrease in 30-day hemorrhage rate, dropping from 2.1% down to 1.0% but associated with higher leak rates from 0.05% to 0.16%

♦Additionally, they found higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%and with an increase in leak rate from 0.1% to 0.2%.

♦They also noted higher ratings for a complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2% with an increase in leak rate from 0.02% to 0.1%

♦They observed surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly.

♦They found Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates and Staple line buttressing was also associated with a similarly small increase in leak rates but was found to be statistically insignificant.

"The clearest signal we got from the study is that completely dissecting out the proximal stomach is essential -- it is associated with better weight loss and reflux outcomes as well as lower bleeding rates," Chhabra told in an interview.

The authors concluded that Variations in surgical technique can be measured by video review and it helps to improve the quality of surgical care and outcomes for patients everywhere.

For further information:

https://jamanetwork.com/journals/jamasurgery/article-abstract/2773954