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Outcomes and Complications After Sleeve Gastrectomy
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How to Manage Sleeve Complications: Hemorrhage
Karl A. Miller
1 Background
Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity among surgeons and patients alike, due to its multiple benefits, which include: maintaining
gastro-intestinal continuity, absence of foreign body, lack of malabsorption, and a
good option of conversion to multiple bariatric procedures [1]. The stomach has an
enriched blood supply via a network of submucous plexus which is derived from
the left and right gastric arteries, gastroepiploic vessels and short gastric arteries. Multiple modalities in the management of bleeding situations are available
(Table 1).
The most significant operative complications of LSG are staple line leak
and bleeding, with reported total complication incidence of up to 13.7% [2–5].
However, hemorrhage, both intra-abdominal and intra-peritoneal, can be more
challenging not only because of their rare occurrence, but also because of their
life-threatening postoperative complication impact following bariatric surgery. The
reported incidence of staple line hemorrhage is up to 3% [2, 3]. However according to the MBSQIB data base, unplanned readmission of patients who had postoperative bleeding within 30 days was up to 21.7% [6]. There is concern that the
actual percentage of patients who experience bleeding is much higher than those
undergoing re-operation which could lead to possible late complications of bleeding, specifically leaks that appear late due to infected hematomas [7].
K. A. Miller (*)
Diakonissen Private Hospital, Salzburg, Austria
e-mail: karl@miller.co.at
K. A. Miller
Kings College Hospital London, Dubai, UAE
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_42
429
K. A. Miller430
Table 1 Modalities in
hemostasis
Mechanical techniques
• Direct pressure
• Sutures
• Staples
• Ligating clips
• Fabric pads
• Gauzes
• Sponges
• Blood component/replacement therapy
Thermal techniques
• Electrocautery
• Hemostatic scalpel
• Laser
• Radiofrequency
Chemical techniques
• Pharmacotherapy
• Hypotensive anesthesia
• Epinephrine
• Vitamin K
• Protamine
• Desmopressin
• Aminocaproic acid
• Tranexamic acid
Topical hemostats
• Collagen
• Cellulose
• Gelatins
• Thrombins
Topical sealants and adhesives
• Fibrin sealants
• Synthetic glues
Multiple attempts to reduce the incidence of these complications have been
done by staple line reinforcement (SLR) with synthetic or biologic material or
suturing, but the evidence is equivocal; hence, there is no consensus with respect
to the best method for SLR or its necessity [8–10]. Having mentioned that, it is
important to emphasize that postoperative bleeding does not only occur at the staple line even though such bleeding has a reported incidence between 55 and 57%.
The occurrence of post-operative bleeding that require re-operation, varies from
20 to 69% [11, 12].
Postoperative hemoglobin and heart rate are associated with bleeding but
not systolic blood pressure or patient characteristics. Further research would be
needed to develop a robust predictive model [13]. Multiple factors that could affect
hemostasis during surgery are summarized in Table 1. Computed tomography
How to Manage Sleeve Complications: Hemorrhage
431
(CT) scan can be used in the stable patient and can be important in differentiating between the locations. In the case of the intraperitoneal bleeding, the CT can
visualize a fluid collection in an extra luminal location; whereas, in the intralumenal bleeding there may be clot seen in the lumen of the bowel or distention of
the remnant stomach. Patients who are hemodynamically unstable as well as those
with an important intraperitoneal hematoma are candidates for surgery. Surgical
exploration allows blood clots evacuation and eventually the identification and
treatment of the bleeding source. Evacuation of the hematoma simplifies the postoperative course because spontaneous resorption is longer and needs monitoring.
Furthermore, the hematoma can open into the stomach through the staple line and/
or get infected secondarily. In case of intraluminal bleeding at the staple line that
persists after conservative treatment, endoscopy can achieve hemostasis. In case
of endoscopic failure or impossibility to perform endoscopy, hemostasis can be
achieved by oversewing the entire staple line with sutures.
2 Bleeding Cascade, Patient and Surgeon Factor
Hemorrhage after LSG is multifactorial and therefore bleeding cascade and
patient factors should be addressed briefly. A simplified major pathway version
of the clotting cascade, emphasizing two mechanisms for initiating blood clotting is shown in Fig. 1. These are the contact activation pathway (also known as
the intrinsic pathway), and the tissue factor pathway (also known as the extrinsic
pathway), which both lead to the reactions that produce fibrin. The primary pathway for the initiation of blood coagulation is the tissue factor or extrinsic pathway.
Various substances are required for the proper functioning of the coagulation cascade such as Calcium and Phospholipid, Vitamin K, and several Regulators.
Medications may interfere with the platelet clot and fibrin clot formation
(Fig. 1). In addition, pathogenic bacteria may secrete agents that alter the coagulation system, such as coagulase and streptokinase which use this enzyme to break
up blood clots [14].
Fig. 1 The hemostatic cascade and antithrombotic medications that disrupt the ability to form a
clot
K. A. Miller432
Aminian et al. analyzed the data of 5871 cases of primary LSG extracted
from the American College of Surgeons National Surgical Quality Improvement
Program (ACS-NSQIP) database. Several factors that contributed to the risk of
serious adverse events were identified as follows: diabetes, body mass index, male
sex, congestive heart failure, steroid use, bilirubin level, and hematocrit level [15].
Janik et al. showed in a retrospective multivariate regression analysis several independent risk factors for postoperative hemorrhagic complications, in particular history for hypertension, obstructive sleep apnea, low surgeons experience in bariatric
surgery and no staple line reinforcement use [11]. In that observational study the
surgeon’s level of expertise in bariatric surgery is essential, demonstrating significantly less hemorrhagic complications among experienced surgeons. According to
the literature, the technical skill of practicing bariatric surgeons varies widely, and
greater skill is associated with fewer postoperative complications and lower rates
of reoperation, readmission, and less visits to the emergency department [16].
However in the Michigan Bariatric Collaborative, surgical skill did not affect the
bleeding rate in the early postoperative period, nor the postoperative weight loss or
resolution of medical comorbidities.[17].
Recently an observation was made that routine elevation of systolic blood pressure (SBP) to 140 mmHg at the end of stomach resection to identify bleeding and
oversewing the staple line minimized hemorrhagic complications [7, 12].
3 Surgical Stapler Technology
Stapler technology has aided in advancing surgical techniques and have shortened operative time and improved perioperative safety [18]. The development
and improvement of stapling devices in which cartridges are manufactured with a
variety of different staple heights, correspond to the thickness of the intended tissue and allows a perfect staple formation to the relevant tissue [19]. Kimura and
Terashita demonstrated in an experimental study the superiority of the shapes of
the formed staples with powered stapling devices. The intestine is not fixed completely with the stapler after the squeezing motion. Deviation of the intestine
occurs even when the stapling is being performed. In addition to this, tremors of
the hands and staplers plus suspension and resumption of stapling result in further
deviation of the intestine. Malformations of the staples were fewer with powered
stapling devices. They concluded that powered staplers possibly result in more
reliable and secure stapling [20]. Better formed staples could potentially produce
fewer leaks and bleeding complications postoperatively [21–24].
The clinical relevance of powered stapling technology is demonstrated in a
“Premier Perspective Hospital Database Study”, in which 31.409 Patients were
identified as having either powered or manual stapling performed during the bariatric procedure. The adjusted rate of bleeding and/or transfusion during the hospital admission was significantly lower (24%) in the powered vs manual stapler
group. In addition the adjusted mean total hospital costs and supply costs were
statistically significantly lower in the powered vs manual stapler group [25].
How to Manage Sleeve Complications: Hemorrhage
433
Additional innovation was developed in the Gripping Surface Technology
(GST) of the cartridge deck. Fegelman et at. could demonstrate, that in the use
of the GST stapling system a reduced need for staple line interventions as nonprophylactic actions taken in response to bleeding along the staple line following
tissue transection, was necessary. The use of the GST stapling system reduces the
need for staple line interventions in LSG [26].
4 Management and Prevention
High costs are an additional argument to reduce complication rate such as leak
and bleeding. Prolonged hospitalization in the ward and intensive care unit will
account for the costs of bleeding, 50% and 35% respectively [27]. Bleeding can
occur during the division of the greater curvature vessels or during gastric stapling. The division of the short gastric vessels during the mobilization of the gastric fundus in proximity to the splenic upper pole particularly exposes to the risk
of hemorrhage. In case of bleeding, the injured vessel can retract, making any
attempts to achieve hemostasis very difficult. If bleeding occurs, mechanical compression should be attempted first followed by the placement of hemostatic gauze.
Mechanical hemostats, adhesives with patch or sealants should always be available
in anticipation of potential bleeding with anatomical difficult access and situations
with potential rebleeding risk [28].
The bleeding on the staple line can be controlled by stitches, metallic clips or
bipolar coagulation which has been a controversial practice. The rebleeding risk
can be treated with hemostats. All these techniques are generally very effective
and conversion to laparotomy due to bleeding is unusual. Appropriate staple size
(height) for the tissue is recommended. Using longer staple height for thin tissues
may cause bleeding from stapler line or intraluminal bleeding at the site. These
may lead to early postoperative intra-abdominal or upper gastrointestinal (GI)
hemorrhage. On the other hand, using short height cartridges on a thick tissue can
be a risk factor for leakage from the anastomosis or staple line, or can create serosal tearing and bleeding. These differing staple heights are designed to ensure that,
when closed, the staples provide secure apposition of the edges of the bowel [29].
Shipping safety cover should not be removed until the cartridge is loaded into the
Stapler. Handling of the instrument must be motion free while firing, avoiding tension on the stapling tissue. Usually, waiting at least 15 s before firing allows adequate compression time before cutting the tissue by staplers [30–32].
The author’s recommended checklist before, during and after linear stapling is
shown in Table 2.
4.1 Buttressing, Oversewing
Buttressing material has been shown to ensure more even distribution of the staple pressure over a wider surface area thus resulting in higher burst pressures and
K. A. Miller434
Table 2 Factors that could affect hemostasis during surgery
Surgical
• Disease state—certain conditions lead to increased bleeding from compromised tissue
• Medications may interfere with clot formation
• Patient factors such as bmi, age, vitamin deficiencies and smoking obstructive sleep apnea
• Blood pressure
• Anesthesia routine (e.g. amount of infusions)
• Surgeons expertise
Mechanical
• Buttressing
• Oversewing
• Clips
• Prophylactic use of hemostats
• Surgical technique in the use of the stapling device (dissection, tissue compression, tissue
tension, staple height)
• Stapler technology
lower bleed rates [29]. Although gastric wall thickness has been reported to vary,
it is thick in the antrum (3.1 mm), moderate in the body (2.4 mm), and thin in the
fundus (1.7 mm), the choice of staple height is very important when a buttressing material is added. The height of the buttress decreases the actual height of the
staple, and a longer staple height should be considered for safe and proper closure
[29, 33]. A number of materials have been studied in staple-line reinforcement,
including porcine small intestinal submucosa strips [34], absorbable polyglycolic
acid [35] and bovine pericardial strips [36, 37]. The use of integrated absorbable synthetic polymers has proved feasible and well tolerated [38], and glycolide copolymer reinforcement sleeves have been shown to reduce staple-line
bleeding and may reduce gastrointestinal hemorrhaging [24, 39]. However in literature reviews Knapps reported that mortality, bleeding, and reintervention rates
were not affected by reinforcement and that there is no statistical difference in the
pooled rate of bleeding, or reintervention [10]. Shikora analyzed out of 253 primary included studies and abstracts 215 bleed study arms the two most commonly
used buttresses, bovine pericardium and a biocompatible glycolide copolymer
buttress [23]. In this meta analyzes the total bleed rate was 3.45%. Overall, reinforcing with bovine pericardium had the lowest bleed rate of 1.23%. Buttressing
with a biocompatible glycolide copolymer resulted in a bleed rate of 2.48% but
had significantly lower bleed rates than no reinforcement. However inconsistency
is seen in systematic reviews and meta analyses, where the incidence of bleeding
is 0–6.7% without reinforcement and 0–8% with reinforcement [10], and comparative studies which did not find a statistically significant decrease in staple line
hemorrhage [21]. Stapler with preloaded buttress material could potentially provide ease of use, might have less staple line bleeding and reduced waste in the
operating room [48, 49]. Conflicting results make it difficult to generally justify
the use of buttressing materials to reduce staple line bleeding most probably also
How to Manage Sleeve Complications: Hemorrhage
435
because of a lack of a consistent definition of post-operative staple line bleeding
[38, 40–45].
Oversewing the staple line with a continuous suture has been used widely to
reduce postoperative complications after LSG [45]. However, Choi et al. suggested
that oversewing could reduce the frequency of leak but that it might increase the
risk of bleeding after LSG although the results were not statistically significant
[21]. Oversewing itself could be potentially dangerous. Tearing at the point of
suture penetration may increase bleeding and leak, and the running suture could
cause sleeve stricture and tissue ischemia [29, 46]. On one hand, studies have
shown that the rates of sleeve stenosis and hematoma formation respectively
were significantly higher in the oversewing group [30, 47]. In a meta-analysis of
7 prospective randomized studies, Wang et al. found no significant difference in
staple line bleeding between oversewing and no staple line treatment but it does
prolong the operative time [8]. In addition omentopexy technique have shown no
significant difference in bleeding, thrombosis, gastric reflux or gastric stenosis but
increased operating time as well, compared to no omentopexy [50].
Despite the disagreement observed when reviewing the recent literature, staple
line reinforcement might play a role in high risk patients in prevention of postoperative bleeding and rebleeding.
5 Hemostats
A wide variety of hemostatic agents (Table 4) are available as adjunctive measures
to improve hemostasis during surgical procedures if residual bleeding persists
despite correct standard surgical technique (eg, electrocautery, sutures) for
hemorrhage control. Topical and tissue adhesives are particularly useful for diffuse
nonanatomic bleeding, bleeding associated with sensitive structures, and bleeding
in patients with hemostatic abnormalities. Active Hemostatic agents are considered active agents, since containing fibrinogen and thrombin, actively participating
at the end of the coagulation cascade to form a fibrin clot [51]. Hemostats can
be used effectively in different scenarios in patients with spontaneous oozing or
drug-induced coagulation disorders in LSG [Table 3]. The most important fac-
tors are the ability of a product to achieve and maintain hemostasis and the speed
in which bleeding is controlled [52]. Adhesives (Liquid fibrin adhesives, Fibrin
patch), mechanical hemostats, sealants can be used either in different bleeding situations or to apply it in reducing the rebleeding risk.
Adhesives are active agents which participate at the final step of the coagulation
cascade to form a fibrin clot (Fig. 1). They are made of two components: human
purified fibrinogen and/or thrombin [53]. Sroka et al. have shown in a prospective
randomized study that the routine use of fibrin sealant in LSG has little benefit to
reduce hemorrhagic complications [54]. Bülbüller et al. conducted a four-arm randomized trial with a total of 65 patients. They had no bleeding complications, but
severe complications in the barbed oversewing group [54]. Musella et al. has so
K. A. Miller436
Table 3 Checklist in linear
gastric stapling (K. Miller)
Table 4 Addressing surgical bleeding situations with adjunctive hemostats
Bleeding situation Problem definition
Continuous quzing • Will not stop with compression
Problematic bleeding • Is accessible but could be dif-
Difficult to access • Occurs in tight and irregular
Rebleeding risk • Is addressed intraoperatively
Closing of the device
• No bunching at crotch √
• Crotch staple removed √
• Staple height appropriate √
• Device parallel to the tissue √
• Tension on the stomach released √
Before firing
• Tissue compression 15 s √
• Interrupted firing if indicated (e.g. thick tissue) √
After firing check staple line
• Check staple line of B-formed staples √
• Leak proof test √
• Hemostasis if indicated or necessary √
Possible use of hemostats
Oxidized regenerated cellulose
or simple packing
• Is more time consuming than
difficult
ficult to expose
• Is more than routine bleeding
• Requires immediate attention
• Disruptive to the normal progression of surgery
spaces
• Can not be precisely visualized
• Raises concerns that accessing
the space will cause more harm
• Could later develop into more
serious complications especially
in high risk patients
(ORC)
Fibrin/thrombin matrix (patch)
Flowable gelatin
Fibrin sealant
far shown also in a prospective randomized trial the use of fibrin sealant in LSG to
significantly reduce postoperative bleeding [55].
Mechanical hemostats provide platelet activation and aggregation and form a
matrix at the site of bleeding, which allows clotting to occur. Oxidized cellulose
regenerated or non-regenerated [56, 57], porcine gelatin [58], bovine collagen
[59], and plant-derived polysaccharides spheres [60], are known as mechanical
hemostats, by providing platelet activation and aggregation. Mechanical hemostats