Does Experience Preclude Leaks in Laparoscopic GB?
Does Experience Preclude Leaks in Laparoscopic GB?
Abstract & Commentary
By Richard M. Peterson, MD, MPH, Clinical Instructor of Surgery, Department of Surgery, USC. Dr. Peterson reports no financial relationship relevant to this field of study.
Synopsis: The incidence of staple-line leaks appears to be independent of the number of LRYGBs performed. These data suggest that surgeons' experience may not eliminate anastomotic complications experienced by patients undergoing LRYGB.
Source: Gonzalez R, et al. Does experience preclude leaks in laparoscopic gastric bypass? Surg Endosc. 2006;20:1687-1692.
Background improved outcomes of Laparoscopic Roux-en-Y gastric bypass (LRYGB) have been demonstrated once practice has moved beyond the learning curve. However, there is no evidence that experience has a favorable impact on the incidence of leaks. This study evaluated the incidence of staple-line leaks as experience accrued in a university-based bariatric surgery program.
Methods: Prospectively collected data on our first 200 patients undergoing LRYGB since July 1998 were analyzed. Linear staplers were used to divide the stomach and to create a side-to-side jejunojejunostomy. A side-to-side cardiojejunostomy was created using a 21-mm circular stapler. Patient characteristics, operative data, and outcomes were evaluated chronologically, with comparison of outcomes between quartiles.
Results: Staple-line leaks developed in 9 (4.5%) of the first 200 patients undergoing LRYGB. Among the 200 patients, there were 190 women (95%). The median age of the patients was 48 years (ranges, 24-62 years), and their body mass index was 43 kg/m2 (ranges, 32-59 kg/m2). As surgeons' experience increased over time, there was a significant increase in the weight of patients and the percentage of patients with previous abdominal operations. There also was a significant decrease in conversion rates and operative times. Leaks occurred in 6 patients at the cardiojejunostomy (3%), in 2 patients jejunojejunostomy (1%), and in one patient at the excluded stomach (0.5%). Of the 50 leaks that occurred in each quartile, there were 3 in the 1st quartile, one in the 2nd quartile, 2 in the 3rd quartile, and 3 in the 4th quartile. The differences were not significant. There was no correlation between the number of LRYGBs, and the occurrence of a leak (P = 0.59 confidence interval 0.13-0.22).
Commentary
The incidence of staple-line leaks appears to be independent of the number of LRYGBs performed. These data suggest that surgeons' experience may not eliminate anastomotic complications experienced by patients undergoing LRYGB.
Gonzalez and colleagues provided an interesting article that was surprising. They analyzed their data on LRYGB and noted that even after developing significant experience with the operation that the incidence of staple line leak seemed to remain relatively constant. They broke down their analysis into quartiles, each containing 50 patients. Their data do show a significant improvement in 2 areas of measure after the first 100 patients (quartiles 1 and 2). This first 100 patients constitutes their learning curve as has been established previously in the literature and corroborated in several studies. Their improved measures were OR time (decreased from 305 minutes to 218 minutes) and conversion rates (decreased from 7% to 1%). The interesting finding in their data was that the complication rate did not decrease with their experience. This may be because as the surgeons improved their technique and operative skill, they were more likely to take on more complicated patients. This was evidenced by the increase in patient average BMI from quartile 1 to 4 (44 to 48 although statistically not significant), an increase in patient comorbidities and an increase in patients with previous operations (both found to be statistically significant).
A second reason, however, may be that the analysis of their patients is too small of a sample size. Their data analysis for the purposes of their publication ended in 2004. It would be very interesting to see if their current data still support this conclusion. If it does still support the conclusion then the question becomes is the problem attributable to the technique or possibly the device? Even with the previously stated learning curve of 100 cases for the LRYGB, the process of improvement in these complex cases continues far beyond that. Even in our own data we have seen differences and improvements in our patients' outcomes with decreases in operative times and decreases in both early and late complications but we have also noted small changes in our technique over that period.
The real take home message from a paper like this is that even as surgeon experience increases, technical challenges still abound and must be addressed meticulously.
The incidence of staple-line leaks appears to be independent of the number of LRYGBs performed. These data suggest that surgeons' experience may not eliminate anastomotic complications experienced by patients undergoing LRYGB.Subscribe Now for Access
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