Abu-Ghanem Yasmin, Meydan Chanan, Segev Lior, Rubin Moshe, Blumenfeld Orit, Spivak Hadar
Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel.
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Obes Surg. 2017 Mar;27(3):837-843. doi: 10.1007/s11695-016-2516-2.
Little evidence is available on the choice of linear staple reloads in laparoscopic sleeve gastrectomy (LSG). Previous literature recommends matching closed staple height (CSH) to tissue-thickness (TT) to avoid ischemia. Our objective was to examine feasibility and safety of "tight" hemostatic (CSH/TT <1) stapling and map the entire gastric wall TT in LSG patients.
Prospectively collected outcomes on 202 consecutive patients who underwent LSG with tight order of staples (Ethicon Endosurgery) in this order: pre-pylorus-black (CSH = 2.3 mm), antrum-green (CSH = 2.0 mm), antrum/body-blue (CSH = 1.5 mm), and white (CSH = 1.0 mm) on the body and fundus. Measurements of entire gastric wall TT were made on the first 100 patients' gastric specimens with an electronic-dogmatic indicator.
Study included 147 females and 55 males with a mean age of 41.5 ± 11.9 years and body mass index of 41.5 ± 3.8 kg/m. Gastric wall measurements revealed mean CSH/TT ratio <1, decreasing from 0.7 ± 0.1 at pre-pylorus to 0.5 ± 0.1 at the fundus. There were 3.1% mechanical failures, mainly (68%) at pre-pylorus-black reloads. Post-operative bleeding occurred in 5 (2.5%) patients. There were no leaks or clinical evidence of sleeve ischemia. Stepwise regression analysis revealed that body mass index (P < 0.001), hypertension (P < 0.01), and male gender (P < 0.001) were associated with increased gastric TT.
Our study suggests that reloads with CSH/TT <1 in LSG including staples with CSH of 1 mm on body and fundus are safe. The results challenge the concept that tight stapling cause's ischemia. Since tight reloads are designed to improve hemostasis, their application could have clinical benefit.
关于腹腔镜袖状胃切除术（LSG）中直线型吻合器钉仓的选择，目前证据较少。既往文献建议使闭合钉高（CSH）与组织厚度（TT）相匹配以避免缺血。我们的目的是研究“紧密”止血（CSH/TT<1）吻合的可行性和安全性，并绘制LSG患者整个胃壁的TT图。
前瞻性收集了连续202例行LSG且按此顺序使用紧密型吻合器钉仓（爱惜康内镜外科）的患者的结果：幽门前黑色（CSH = 2.3mm）、胃窦绿色（CSH = 2.0mm）、胃窦/胃体蓝色（CSH = 1.5mm）以及胃体和胃底白色（CSH = 1.0mm）。使用电子教条式指示器对前100例患者的胃标本进行整个胃壁TT的测量。
研究纳入147例女性和55例男性，平均年龄41.5±11.9岁，体重指数41.5±3.8kg/m²。胃壁测量显示平均CSH/TT比值<1，从幽门前的0.7±0.1降至胃底的0.5±0.1。机械故障发生率为3.1%，主要（68%）发生在幽门前黑色钉仓。5例（2.5%）患者术后出血。未发生渗漏或袖状胃缺血的临床证据。逐步回归分析显示，体重指数（P<0.001）、高血压（P<0.01）和男性（P<0.001）与胃TT增加相关。
我们的研究表明，LSG中使用CSH/TT<1的钉仓包括胃体和胃底CSH为1mm的钉仓是安全的。结果挑战了紧密吻合会导致缺血的概念。由于紧密型钉仓旨在改善止血，其应用可能具有临床益处。
