• Elizabeth R Berger, Ronald H Clements, John M Morton, Kristopher M Huffman, Bruce M Wolfe, Ninh T Nguyen, Clifford Y Ko, and Matthew M Hutter.
• *Loyola University Chicago Stritch School of Medicine, Chicago, IL †Vanderbilt University Medical Center, Nashville, TM ‡Stanford University Medical Center, Stanford, CA §Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL American College of Surgeons, Chicago, IL ||Oregon Health and Science University, Portland, OR ¶University of California, Irvine School of Medicine, Irvine, CA #University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA **Department of Surgery, Massachusetts General Hospital, Boston, MA.
• Ann. Surg. 2016 Sep 1; 264 (3): 464-73.

ObjectiveQuestions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year.MethodsUsing the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level.ResultsA total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00-1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63-0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62-0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80-0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP.ConclusionLSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.

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