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Kheirvari et al. Mini-invasive Surg 2020;4:3 I http://dx.doi.org/10.20517/2574-1225.2019.45 Page 5 of 7

Table 2. Binary logistic regression models results (odds ratio)
Unadjusted model Adjusted model
Variables
OR (95%CI) P value OR (95%CI) P value
Sex 0.99 (0.49-1.99) 0.979 0.94 (0.38-2.34) 0.909
Age 0.98 (0.95-1.02) 0.490 0.95 (0.917-1.01) 0.056
ESR 1.051 (1.036-1.066) 0.000 1.054 (1.038-1.070) 0.000
ESR: Erythrocyte sedimentation rate; OR: odds ratio

According to the results, ESR serum level in patients with leak after sleeve gastrectomy was significantly
increased in comparison with ESR levels of patients without any complications after the surgery. The mean
ESR serum levels were 73.1 mm/h for cases and 31.34 mm/h for controls.

As mentioned above, high ESR serum levels can be seen in various conditions such as cardiovascular and
kidney disease and obstructive sleep apnea [14,15] . However, after bariatric surgery, patients with obesity
start to lose weight, which may lead to an increase in ESR serum levels, but mean ESR in patients with leak
compared to control group was significantly higher. Thus, for every 1 unit increase in ESR serum levels,
the odds for leakage occurrence increase by 5.1% in patients after bariatric surgery. The normal range
[15]
of ESR for men is 0-22 mm/h and 0-29 mm/h for women , but in subjects with obesity, due to a series
of interactions, it can be elevated. Macrophages and adipose tissue secrete cytokines and interleukins,
resulting in stimulation of liver to produce fibrinogen, CRP, and haptoglobin, which in turn elevate ESR
[15]
serum levels during inflammation [Figure 1] . Therefore, with this diagnostic value of ESR, surgeons
can employ ESR serum levels immediately after procedure, instead of common interventions that might
[6]
increase the cost and duration of treatment . In vulnerable patients with abnormal ESR levels, a series
of technical recommendations can be done to prevent leakage after operation, including use a 40 Fr size
or more bougie, initiate the gastric transection 5-6 cm from the pylorus, use proper cartridge colors from
[5]
[6]
antrum to fundus, reinforce the staple line with buttress material , order an appropriate staple line ,
perform an intraoperative methylene blue test, remove the crotch staples, maintain suitable traction on the
stomach before firing, avert from the angle of His (at least 1 cm), and check the staple line bleeding during
the procedure.

Although gastric leakage can be caused by either mechanical or ischemic reasons, ESR serum levels might
be a reliable predictor for postoperative leakage. Hence, in patients with higher ESR, more sedulous
management (leaving a shorter antrum and using a smaller bougie) can be performed by surgeons and this
may open a new chapter in terms of personalized surgery with fewer cases of leak complications among
subjects. Previous studies have not paid sufficient attention to the molecular dimension of gastric leak;
instead, most studies have focused on mechanical dimension and the management of this complication.
Researchers have found that a greater bougie is related to a leakage rate of 0.6% in comparison with those
[16]
[17]
who used smaller sizes whose leak rate was 2.8% . However, Keren et al. reported normal ESR levels of
patients with gastric leakage, which is in contrast to our findings.
Other variables including sex, age, platelet count, and CRP serum level were not significantly different
[17]
[18]
compared to control patients. In line with these results, Keren et al. in 2015 and Surace et al. in 2011
reported that gastric leak after sleeve gastrectomy presents no correlation with serum levels of CRP and
WBC [17,18] . Nevertheless, more studies are warranted to address the question of why ESR serum level has
been increased without any significant changes in CRP levels.

In conclusions, this study reports the clinical correlation of gastric leakage and platelet count, ESR, and CRP
serum levels and gives practical instructions to prevent and manage leaks after sleeve gastrectomy. In short,
these recommendations are: (1) use greater size of bougie; (2) begin the gastric transection 5-6 cm from