Laparoscopic sleeve gastrectomy (LSG) has become the most popular bariatric procedure in many countries in the world. The increasing popularity of LSG is attributed to its excellent outcome with regard to weight loss and improvement in comorbidities [Citation1]. However, despite having a satisfactory safety profile, LSG may be associated with some serious complications.
LSG involves a staple line that can be considered among the longest staple lines in gastrointestinal surgery. Having such a long staple line could be associated with increased risk of staple line complications, namely staple line leakage and bleeding [Citation2]. In order to maintain the safety profile of LSG, several investigators assessed different methods to reduce the incidence of staple line complications after LSG.
Although the overall rates of staple line bleeding and leakage after LSG are generally low (up to 3% for staple line bleeding and up to 1.76% for staple line leakage) [Citation1,Citation3], the consequences of these complications can be severe enough to be life threatening to the patients. A recent study looked at the risk factors and impact of staple line leakage after LSG, and despite being an infrequent event with an incidence of 1.5%, staple line leakage resulted in a significant increase of the mortality rate from 0.2% to 3.7% [Citation2].
Staple line bleeding may occur in up to 2% of patients after LSG and is mostly attributed to inefficient sealing of small branches of the gastroepiploic and short gastric arteries by energy devices during dissection of the greater curvature of the stomach or due to technical failure of the staplers [Citation4]. Having a rich network of blood supply, bleeding from the stomach can be quite profuse and may lead to hemodynamic instability and shock.
In light of the dire consequences of staple line complications, different methods were devised to prevent their incidence. These methods include using larger bougie, routine methylene blue test to check for leakage, staple line reinforcement by oversewing or buttering it, staple line inversion and distal fixation, and the intraoperative use of tranexamic acid [Citation5–8].
One of the methods frequently used by bariatric surgeons to reinforce the staple line of LSG is to oversew it. A meta-analysis [Citation3] of randomized controlled trials tried to address the question whether oversewing the staple line of LSG is necessary to prevent or reduce staple line leakage and bleeding. Four different databases were comprehensively reviewed and 11 randomized trials comprising more than 2400 patients were finally included.
Despite having a longer operative time, the results of the meta-analysis were in favor of oversewing the staple line as it managed to reduce the incidence of staple line bleeding by 52% and minimize the rate of staple line leakage by 56%. Interestingly, there was no significant heterogeneity among the studies with regard to the incidence of staple line complication in each study as demonstrated by inconsistency index of zero percent.
This meta-analysis can be considered the largest evidence on the efficacy of staple line reinforcement as it included larger number of patients compared to previous similar meta-analyses. The high quality of the randomized trials included and the absence of publication bias among them further support the conclusions of the review. Although different staples and sutures were used for oversewing the staple line in the studies included, which may be a source of heterogeneity, the final conclusion of the meta-analysis that oversewing the staple line can effectively reduce postoperative complications remains highly reasonable and valid.
Finally, a word of caution about oversewing the staple line is that while it tends to prevent bleeding by constricting the blood vessels and increasing pressure resistance inside them; oversewing can compromise the blood supply of the staple line if performed tightly, resulting in poor healing and perhaps dehiscence of the staple line, and subsequently gastric leakage. Therefore, staple line oversewing should be only applied by bariatric surgeons who have enough experience and skills, as implied by the meta-analysis [Citation3].
Declaration of interest
None to be disclosed by the author.
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