Page 34 - Read Online

Kheirvari et al. Mini-invasive Surg 2020;4:3 I http://dx.doi.org/10.20517/2574-1225.2019.45 Page 3 of 7

METHODS
Data source
We performed a retrospective cohort study using the database of Erfan Niayesh Hospital bariatric
procedures performed by Taha Anbara, Laparoscopic Surgeon, MD.

Surgical procedure
Sleeve gastrectomy was performed on all subjects according to the standard protocol and in a similar
method by a specific surgeon with similar tools during the same duration. After prep and draping under
GA, a 10-mm trocar canula (Covidien, Cincinnati, OH) is inserted above the amblicus. Then, three 5-mm
trocar canulas and one 15-mm canula (Covidien, Cincinnati, OH) are inserted under direct vision in the
proper place. The gastrocholical ligament is divided with ligature. Then, the sleeve gastrectomy is done
with seven 4.5-mm staples (black cartridges). The divided part of the stomach is taken out later and the
place of staple line is sutured with 2-0 yarn. Afterwards, the drain is placed at gastrectomy site. The canulas
are taken out later under direct sight and then, when homeostasis is reliable, abdominal gas is drained and
the place of Canula 10 is repaired. To determine leakage, we transiently block the flow into the duodenum
with long intestinal forceps at the pyloric channel. The removed specimen, which is removed easily
through the 15-mm port at the right upper abdominal quadrant, is sent for histological analysis. Finally,
one silastic drain is always left at side of the gastric suture line.

Clinical evaluation
Clinical sign and symptoms were repeatedly surveyed for all subjects every 6 h after surgery. Intraoperative
gastrointestinal leakage was not observed during procedure in any subjects.

Study design and population
Clinical data on 199 adult obese subjects who underwent sleeve gastrectomy were evaluated according to
the Current Procedural Terminology code: LSG (43,775). Approval for the use of the data in this study
was obtained from the Efran-Niyayesh Hospital. Subjects were categorized into two groups, those who
experienced postoperative gastrointestinal leakage (Cases) and those without any types of leakage, whether
intraoperative or after procedure (Control). Preoperative co-morbidities and characteristics were examined
to determine predictive factors of leakage. Oral contrast was given during the study and the contrast was
followed when it went from the mouth to the small intestine. Emergent, revisional, and converted cases
were excluded. The time and location of appearance and closure of leakages were diligently recorded in all
cases.

Definition of leakage
The UK Surgical Infection Study Group has defined a standard definition of anastomotic leakage: “the
leak of luminal contents from a surgical join between two hollow viscera”. It may also demonstrate a
gastrointestinal leak in a suture line around the organ. According to the time of leakage appearance, they
[14]
have previously been classified as follows: early (leaks appearing 1-3 days after procedure), intermediate
(leaks appearing four days to a week after surgery), and late (leaks appearing more than one week after
procedure).

Patients
Fifty cases who had postoperative gastrointestinal leakage were considered in the study as well as 149
control cases (ratio 3:1) randomly selected to increase the reliability of the study. The information of
control cases was extracted from the medical records of Erfan-Niyayesh Hospital. All cases underwent
sleeve gastrectomy during 2017-2019 in Erfan-Niyayesh Hospital under supervision of the same surgeon
with the same tools. The variables used in the multivariate analyses included demographic data (BMI, age,
and gender), preoperative co-morbidities, procedural type, and various intraoperative and postoperative
interventions.