Leaks after sleeve gastrectomy: is it still an issue?—single-center experience and systematic literature review

Introduction

For the past 20 years, laparoscopic sleeve gastrectomy (SG) has been performed either as a first step or as a standalone treatment for morbid obesity, becoming the first-choice treatment option for many bariatric surgeons and patients (1). In fact, SG currently represents the utmost prevalent operation on a global scale and this comes as a result of its well-established and widely proven efficacy and safety profile (2-5).

Although SG is considered a simple procedure from a technical point of view, complications may still arise. The most frequent postoperative complications include staple line leaks, bleeding, and strictures (6). The disruption of the staple line with the development of a gastric leak or fistula is, by all means, the most feared complication, due to its prolonged hospitalization and significant morbidity (7,8). The pathogenesis of gastric leaks after SG seems to be multifactorial. Several aspects have been proposed to be implicated in its development, such as poor blood perfusion, reduced distance of the staple line from the gastroesophageal junction, and mid-gastric stricture leading to increased endoluminal pressure (9). Various methods and techniques have been implemented in the hopes of possibly reducing such a dreaded complication. Most of these methods have focused on reinforcing the staple line by means of clips, oversewing with running sutures, placement of buttressing material or sealants. Despite these technical preventive measures, some authors showed no significant reduction in leak rates (9).

Based on the data of the International Sleeve Gastrectomy Expert Panel Consensus Statement 2011, the leak rate is an estimated 1.06% (10). However, the incidence has also been reported to reach 7% (11) for primary procedures and more than 10% after revisional surgery (10-13). Since the first laparoscopic SG, described in 2003, gastric leak incidence has progressively diminished in parallel with the concomitant increase in the number of patients treated with this procedure each year (14-16).

The aim of this study was to compare the incidence of gastric leaks in patients undergoing SG during different time periods, by matching two cohorts of patients: those who underwent SG prior to 2011 (group A) and those who underwent SG after 2011 (group B). Furthermore, we systematically reviewed the literature evaluating the overall rate of gastric leaks post-SG reported between 2006 and 2020 by subdividing them into three separate 5-year periods. We present this article in accordance with the STROBE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-13/rc).

Methods

Study design

This is a single-institution retrospective study designed to evaluate the incidence of gastric leaks in patients undergoing SG during different time periods. Specifically, two cohorts of patients were matched, those undergoing SG before 2011 (group A) and those who underwent SG after 2011 (group B). This separate time period was arbitrarily decided upon based on our level of expertise and the achievement of a learning curve. Surgeries were performed by two separate surgeons with the same level of expertise in bariatric surgery.

Between October 2006 and December 2020, patients affected by morbid obesity underwent laparoscopic SG at Sapienza University Hospital in Rome, Italy and were considered for the present study. Participants were followed-up for at least 12 months postoperatively to assess the possible development of a gastric leak/fistula. Weight outcomes were evaluated at the 12-month visit during outpatient clinic follow-up to ensure comparability of data between the two groups. Patient inclusion criteria comprised those enlisted by international guidelines (17). Subjects who underwent revisional bariatric surgery were excluded from the study.

All patients underwent a standard preoperative multidisciplinary workup following institutional, national, and international guidelines, involving complete history and physical examination, routine laboratory tests, chest X-ray, abdominal ultrasonography, esophagogastroduodenoscopy (EGD), and nutritional and psychiatric assessment. Additional examinations or specialist consultations were performed when clinically required.

Patients were followed-up by means of physical examination, and routine blood tests at 1, 3, 6, and 12 months postoperatively during outpatient visits. Additionally, patients underwent upper gastrointestinal swallow tests at 1 and 12 months after SG.

Data from a prospectively collected database were retrospectively analyzed. Age, sex, height, weight, body mass index (BMI), obesity-related comorbidities, previous bariatric surgery, and perioperative complications were recorded.

The study was approved by the Ethical Committee of Sapienza University of Rome (Rif. 5487). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Additional written informed consent was obtained before all surgical procedures.

Surgical technique

Our standard surgical procedure for SG has been previously described (18). All surgical procedures were performed laparoscopically by a 5-trocar technique. Full mobilization of the gastric fundus with complete dissection of the posterior gastric wall from the left diaphragmatic crus was achieved. A 48-Fr calibration orogastric bougie was routinely used. Resection was begun approximately 6 cm from the pylorus and continued cephalad reaching the angle of His using an endoscopic linear 60 mm stapler with green cartridges on the lower two-thirds of the sleeve and gold cartridges on the upper third. When used, bioabsorbable buttressing material (GORE^® Seamguard, Newark, DE, USA) was used to reinforce the staple line. A gastric sleeve with a residual capacity of 60–80 mL (as measured by administration of methylene blue saline solution via a nasogastric tube) was achieved.

Review of the literature

A comprehensive literature search was conducted. A total of 315 articles were identified and 100 articles remained after duplicates were removed. The study flow chart is shown in Figure 1. The titles and abstracts of the retrieved articles were screened for applicability. Animal studies, review articles, and articles not on the topic of leak after SG were excluded. Since 2006, laparoscopic SG has started to be one of the standard procedures for the cure of obesity, with a growing number of patients treated each year. Hence, only studies that contained more than 100 patients and were published after 2006 were included in the quantitative analysis, in order to avoid including small case series performed in low-volume centers. The search was performed using the following electronic databases without any year restriction: PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. All abstracts in the English language were screened for applicability. All types of studies were included in the analysis. A manual search using the following keywords extracted from the Medical Subjects Heading (MeSH) was made: ‘leak’ OR ‘gastric fistula’ AND ‘sleeve gastrectomy’ AND ‘bariatric surgery OR ‘metabolic surgery’ AND ‘incidence’ AND ‘prevalence’.

Figure 1 PRISMA 2020 flow diagram.

The full text of the remaining 66 articles was reviewed for eligibility and was included in the analysis.

Retrieved articles were arbitrarily subdivided in three 5-year periods (2006–2010, 2011–2015, and 2016–2020) so as to schematically divide patients and leak rates into different time-periods.

Definitions

For the purposes of this study, in addition to “leak”, the term “gastric fistula” was categorized as a leak. As stated by the United Kingdom Surgical Infection study group, an anastomotic leak can be defined as “a leak of luminal contents from a surgical join between two hollow viscera” (19).

Statistical analysis

In case of normal distribution continuous variables are expressed as means ± standard deviation (SD), otherwise as medians. Ordinal (semiquantitative scores) and non-ordinal categorical variables are expressed as numbers (percentages). Pearson correlation was used to check for determinants of leak occurrence in our population.

Receiver operating characteristic (ROC) curve analysis was generated by the artificial neural network analysis (ANN). A ROC curve analysis was used to assess how accurate a marker is capable of discriminating between leak occurrence or not (20). BMI, age, and comorbidities, such as obstructive sleep apnea (OSA) and hypertension were used as predictors of leak occurrence in our population. In a ROC curve, the true positive rate (sensitivity) is plotted in function of the false positive rate (1 − specificity) for different cutoff points of a parameter. Among the indices of accuracy proposed to summarize ROC curves is the area under the curve (AUC), a unidimensional index. The maximum AUC =1 means that the diagnostic test is perfect in the differentiation between leak occurrence or not (21). A P value <0.05 was considered statistically significant.

All data manipulation and analyses were conducted using SPSS version 27 (22).

Results

Study groups

A total of 875 patients underwent SG as a standalone procedure between 2006 and 2020 in at Sapienza University of Rome. Three-hundred and sixty-one patients were included in group A which consisted of 281 (77.8%) females and 80 (22.2%) males, while group B comprised 514 patients, of which 375 (73%) females and 139 (27%) males. Table 1 describes gender, median [interquartile range (IQR)] age, comorbidity, staple-line reinforcement if any, and weight loss outcomes in the two groups.

Preoperative weight and BMI were significantly greater in group A; however, postoperative BMI was significantly lower in group B compared to group A (28 vs. 27 kg/m², P<0.001). Mean percent weight loss (%WL) was 36.3% and 37.1% in groups A and B, respectively (P=0.90).

Twelve staple line leaks occurred in group A (3.3%); 4 leaks occurred in group B (0.8%) (P=0.008). The overall leak rate was 1.8%. Six out of twelve leaks in group A had no reinforcement. Just one leak in group B had no reinforcement. Staple-line reinforcement was used in 158 (43.8%) patients in group A and 338 (65.7%) in group B (P=0.01). Reinforcement showed a negative significant correlation with the development of leaks (P=0.03).

When looking for determinants of leak occurrence, BMI, age, and comorbidities, such as OSA and hypertension, positively correlated with leak incidence (P=0.02, P=0.05, P=0.008, P=0.01, respectively) (Table 2). When using ANN analysis to assess the predictors of leak occurrence in our population, BMI was a strong predictor of leak incidence (AUC =0.70) (Figure 2).

Figure 2 ANN analysis to assess the predictors of leak occurrence in our population, showing BMI as a strong predictor of leak incidence (AUC =0.70). ANN, artificial neural network; BMI, body mass index; AUC, area under the curve.

Apart from leak, complications emerged in 7.2% of patients in group A and 3.3% of patients in group B.

Review of the literature

A total of 66 studies encompassing 89,407 SG patients were included in the final analysis (Table 3). The publication time frame of 2006–2020 reflected the operative time frame from March 2005 through May 2020 with an increase of the number of SG publications over time.

In total, 923 leaks were reported in 89,407 patients (overall incidence: 1.03%). The leak rate ranged from 3.07% in the first 5-year period, to 1.41% in the second 5-year period, and to 1.37% in the last 5-year period (Figure 3).

Figure 3 Leak rate during the three 5-year periods.

The number of SG procedures increase over time from 3,084 patients treated in the first 5-year period [2006–2010] to 19,776 in the second 5-year period [2011–2015] to 66,547 in the last 5-year period [2016–2020] (Figure 4). The number of performed cases of SG inversely correlated with the percentage of leaks (P<0.05). The greater the number of cases, the lower the percentage of leaks. No significant correlation was found between the number of leaks and the type of reinforcement used or the type of stapler used (P=0.96 and P=0.11, respectively).

Figure 4 Number of SG cases during the three 5-year periods. SG, sleeve gastrectomy.

Discussion

SG is currently the most commonly performed bariatric procedure for the treatment of obesity and its metabolic complications (84). Although a technically simpler operation compared to other bariatric surgical options, this procedure still holds a low, but non-negligible incidence of postoperative complications (16,85-87). The most feared complication is still by all means a staple-line disruption.

In the present study, we sought to identify whether an increased surgeon’s experience during different time periods within Sapienza University of Rome played a role in the development of gastric leaks following SG. We found a significantly different incidence in leak rates between the two analyzed groups. Specifically, a total of 12 leaks occurred in group A (3.3%) and 4 leaks (0.8%) in group B, with an overall leak rate of 1.8% in the two groups. Additionally, BMI loss was substantially greater in the second cohort of patients compared with the former group (group A: 28 vs. group B: 27 kg/m², P<0.001). Our results seem to suggest that the increasing number of SGs performed and the growing experience and expertise of the surgical team hold a fundamental role in the development of leaks and might also improve weight outcomes.

Several authors performed a data analysis on surgeons’ proficiency in performing laparoscopic Roux en Y gastric bypass and evaluated how it affected surgical outcomes. Authors demonstrated how those surgeons who rated better surgical skills yielded lower postoperative complications, with shorter operative time, lower reoperation and readmission rates, and even reduced mortality (88,89). On the contrary, Gil et al. reported a considerable reduction in operative time and gastric stenosis with the advancement of the learning curve of surgeons performing SGs, without differences in the 30-day postoperative complication rate, hospital stay, or weight loss (90).

Furthermore, in the present study, 66 articles reporting gastric leaks after SG were reviewed and analyzed. Within a total sample size of 89,407 patients, 923 leaks were recorded for an overall leak rate of 1.03%. The percentage of leaks decreased from 3.07% to 1.41% in the period going from 2006–2010 to 2011–2015, respectively, and then plateaued to 1.37% in the period between 2011–2015 and 2016–2020. This trend seems to reflect how after an initial learning curve over the first 5-year period, the leak rate reduces by two-fold and tends to stabilize over the second and last analyzed 5-year periods (Figure 3).

As reported by the Fifth International Consensus Conference: Current Status of Sleeve Gastrectomy, the rate of leaks was 2.4% (SD =7.6%; range, 0–54%), although this could reach a proportion as high as 7% (89). Experts tend to believe that the smaller the bougie size and the tighter the sleeve, the higher the incidence of leaks (78.8% vs. 65.2%, P=0.006), hence the inclination to use slightly larger-sized bougies, the median being 36 Fr (91-93).

Six out of 12 leaks in group A had no reinforcement, while just one leak in group B lacked a staple line reinforcement. Reinforcement material was used in 158 (43.8%) patients in group A and 338 (65.7%) in group B (P=0.01). The increased usage and implementation of buttressing material in group B could be the result of the advancement in technologies over time and the greater availability of such resources. Staple line leak directly correlated with the absence of reinforcement (P=0.03). Nevertheless, when reviewing the literature, no significant correlation was found between the number of leaks and the type of reinforcement used or the type of stapler employed (P=0.96 and P=0.11, respectively) (94).

The use of staple line reinforcement or buttressing material in preventing or decreasing the leak rate is still a matter of debate. Numerous studies reported that leak rate can be decreased by reinforcement with oversewing, while others advise the use of PeriStrips Dry (PSD; bovine pericardium with collagen matrix) or the use of fibrin sealants (28,94). As reported in a metanalysis conducted by Parikh et al. (94) no significant difference was found between the use of reinforcement, either by oversewing or through the use of buttressing material, and no reinforcement at all, in terms of leak development. In contrast, a randomized controlled trial, comparing the use of running sutures with invagination of the staple line to no reinforcement, revealed a decrease in leak rates for the suturing strategy, although this led to longer operating time by approximately 18 minutes (93). A recent systematic review by Gagner et al. compared SG leak rates in five options of staple line reinforcement, including no reinforcement, oversewing with sutures, nonabsorbable bovine pericardial strips, tissue sealant or fibrin glue, or absorbable polymer membrane. Contrarily to other studies, authors found a significantly beneficial role of absorbable polymer membrane on leak rates as compared to other analyzed methods (95). Based on such findings, authors postulate that the temporal decrease in leak complications after SG is most likely due to the growing surgical expertise, considering that no modifications in buttressing materials occurred over the past few years.

In fact, several improvements in surgical technique have been implemented in our practice over time and could have contributed, concurrently to the greater use of reinforcements, to a lower incidence of gastric leaks. These include: reduced dissection around the diaphragmatic crura, preserving more vascular tissue and decreasing thermal injury at this level; usage of appropriate bougie size; prevention of strictures at the incisura angularis; appropriate staple height selection based on tissue thickness and avoiding to staple excessively close to the esophagus.

SG represents a valuable option in the shortlist of bariatric surgical procedures thanks to its long-term effectiveness and safety profile. However, with regards to the best SG technique, there is no agreement on bougie size, starting point of transection from the pylorus, or usage of buttressing material. Nevertheless, leaks after SG can lead to an overall mortality of 0.32%, and a leak-related mortality of 0.11% (87). Additionally, they are linked to high costs, causing extended hospital stays especially in intensive care units and higher outpatient expenses. In light of the fact that the primary cause for postoperative morbidity and mortality after SG continues to be staple line leaks, further studies to precisely comprehend the main determinants of such a dreaded complication are warranted.

Some limitations of the present study must be acknowledged. These include the study’s single-institution retrospective design, potentially introducing biases. Potential selection bias and the absence of a randomized control group also pose challenges in establishing a causal link between increased surgeon experience and decreased leak rates. The strengths of the study lie in its longitudinal analysis spanning from 2006 to 2020, involving a large sample size of 875 patients undergoing SG, and the inclusion of matched cohorts before and after 2011, allowing for meaningful comparisons. Overall, while the study offers valuable insights, its limitations underscore the need for cautious interpretation and suggest avenues for further research.

Conclusions

The percentage of leaks significantly decreased over time in our cohorts which reflected literature data. The use of staple line reinforcement seemed to play a substantial role in our personal series but was not consistent with reported evidence. The increasing expertise in parallel with the growing number of SGs performed is associated with a substantial decrease in overall leak rates and might be correlated with improved weight outcomes.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-13/rc

Data Sharing Statement: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-13/dss

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-13/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-13/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Ethical Committee of Sapienza University of Rome (Rif. 5487). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Additional written informed consent was obtained before all surgical procedures.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 2005;15:1124-8. [Crossref] [PubMed]
2. Angrisani L, Santonicola A, Iovino P, et al. IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures. Obes Surg 2018;28:3783-94. [Crossref] [PubMed]
3. Castagneto-Gissey L, Mingrone G. Insulin sensitivity and secretion modifications after bariatric surgery. J Endocrinol Invest 2012;35:692-8. [PubMed]
4. Angelini G, Panunzi S, Castagneto-Gissey L, et al. Accurate liquid biopsy for the diagnosis of non-alcoholic steatohepatitis and liver fibrosis. Gut 2023;72:392-403. [Crossref] [PubMed]
5. Mingrone G, Castagneto-Gissey L. Type 2 diabetes mellitus in 2013: A central role of the gut in glucose homeostasis. Nat Rev Endocrinol 2014;10:73-4. [Crossref] [PubMed]
6. Iannelli A, Treacy P, Sebastianelli L, et al. Perioperative complications of sleeve gastrectomy: Review of the literature. J Minim Access Surg 2019;15:1-7. [Crossref] [PubMed]
7. Benedix F, Benedix DD, Knoll C, et al. Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes Surg 2014;24:1610-6. [Crossref] [PubMed]
8. Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol 2014;20:13904-10. [Crossref] [PubMed]
9. Rosenthal RJInternational Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 2012;8:8-19. [Crossref] [PubMed]
10. Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 2009;145:106-13. [Crossref] [PubMed]
11. Lacy A, Ibarzabal A, Pando E, et al. Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 2010;20:351-6. [Crossref] [PubMed]
12. Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146-51. [Crossref] [PubMed]
13. Iannelli A, Schneck AS, Ragot E, et al. Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty. Obes Surg 2009;19:1216-20. [Crossref] [PubMed]
14. Burgos AM, Braghetto I, Csendes A, et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 2009;19:1672-7. [Crossref] [PubMed]
15. Timucin Aydin M, Aras O, Karip B, et al. Staple Line Reinforcement Methods in Laparoscopic Sleeve Gastrectomy: Comparison of Burst Pressures and Leaks. JSLS 2015;19:e2015.00040.
16. Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007. Obes Surg 2008;18:487-96. [Crossref] [PubMed]
17. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991;115:956-61. [Crossref] [PubMed]
18. Genco A, Castagneto-Gissey L, Gualtieri L, et al. GORD and Barrett's oesophagus after bariatric procedures: multicentre prospective study. Br J Surg 2021;108:1498-505. [Crossref] [PubMed]
19. Peel AL, Taylor EW. Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group. Ann R Coll Surg Engl 1991;73:385-8. [PubMed]
20. Kamarudin AN, Cox T, Kolamunnage-Dona R. Time-dependent ROC curve analysis in medical research: current methods and applications. BMC Med Res Methodol 2017;17:53. [Crossref] [PubMed]
21. Hajian-Tilaki K. Receiver Operating Characteristic (ROC) Curve Analysis for Medical Diagnostic Test Evaluation. Caspian J Intern Med 2013;4:627-35. [PubMed]
22. IBM Corp. IBM SPSS Statistics for Windows, version 27.0. Armonk: IBM Corp. 2020.
23. Lee WJ, Wang W. Bariatric surgery: Asia-Pacific perspective. Obes Surg 2005;15:751-7. [Crossref] [PubMed]
24. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859-63. [Crossref] [PubMed]
25. Nocca D, Krawczykowsky D, Bomans B, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg 2008;18:560-5. [Crossref] [PubMed]
26. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4:33-8. [Crossref] [PubMed]
27. Fuchs KH, Breithaupt W. Natural orifice transluminal endoscopic surgery in future obesity treatment. Chirurg 2008;79:837-42. [Crossref] [PubMed]
28. Casella G, Soricelli E, Rizzello M, et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 2009;19:821-6. [Crossref] [PubMed]
29. Csendes A, Braghetto I, León P, et al. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 2010;14:1343-8. [Crossref] [PubMed]
30. Daskalakis M, Berdan Y, Theodoridou S, et al. Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Surg Endosc 2011;25:88-97. [Crossref] [PubMed]
31. Gluck B, Movitz B, Jansma S, et al. Laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure for the lower BMI (35.0-43.0 kg/m2) population. Obes Surg 2011;21:1168-71. [Crossref] [PubMed]
32. Angrisani L, Cutolo PP, Buchwald JN, et al. Laparoscopic reinforced sleeve gastrectomy: early results and complications. Obes Surg 2011;21:783-93. [Crossref] [PubMed]
33. Albanopoulos K, Alevizos L, Flessas J, et al. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results. Obes Surg 2012;22:42-6. [Crossref] [PubMed]
34. Prasad P, Tantia O, Patle N, et al. An analysis of 1-3-year follow-up results of laparoscopic sleeve gastrectomy: an Indian perspective. Obes Surg 2012;22:507-14. [Crossref] [PubMed]
35. Gill RS, Switzer N, Driedger M, et al. Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients. Obes Surg 2012;22:560-4. [Crossref] [PubMed]
36. Gentileschi P, D'Ugo S, Benavoli D, et al. Staple-line reinforcement with a thrombin matrix during laparoscopic sleeve gastrectomy for morbid obesity: a case series. J Laparoendosc Adv Surg Tech A 2012;22:249-53. [Crossref] [PubMed]
37. Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240-5. [Crossref] [PubMed]
38. Noel P, Iannelli A, Sejor E, et al. Laparoscopic sleeve gastrectomy: how I do it. Surg Laparosc Endosc Percutan Tech 2013;23:e14-6. [Crossref] [PubMed]
39. Weiner RA, El-Sayes IA, Theodoridou S, et al. Early post-operative complications: incidence, management, and impact on length of hospital stay. A retrospective comparison between laparoscopic gastric bypass and sleeve gastrectomy. Obes Surg 2013;23:2004-12. [Crossref] [PubMed]
40. Fridman A, Moon R, Cozacov Y, et al. Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. J Am Coll Surg 2013;217:614-20. [Crossref] [PubMed]
41. Al Hajj GN, Haddad J. Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs. oversewing. Obes Surg 2013;23:1915-21. [Crossref] [PubMed]
42. Badaoui R, Rebibo L, Thiel V, et al. Observational study on outpatient sleeve gastrectomy. Ann Fr Anesth Reanim 2014;33:497-502. [Crossref] [PubMed]
43. Billing PS, Crouthamel MR, Oling S, et al. Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases. Surg Obes Relat Dis 2014;10:101-5. [Crossref] [PubMed]
44. Rossetti G, Fei L, Docimo L, et al. Is nasogastric decompression useful in prevention of leaks after laparoscopic sleeve gastrectomy? A randomized trial. J Invest Surg 2014;27:234-9. [Crossref] [PubMed]
45. Abd Ellatif ME, Abdallah E, Askar W, et al. Long term predictors of success after laparoscopic sleeve gastrectomy. Int J Surg 2014;12:504-8. [Crossref] [PubMed]
46. Hoogerboord M, Wiebe S, Klassen D, et al. Laparoscopic sleeve gastrectomy: perioperative outcomes, weight loss and impact on type 2 diabetes mellitus over 2 years. Can J Surg 2014;57:101-5. [Crossref] [PubMed]
47. Durmush EK, Ermerak G, Durmush D. Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter? Obes Surg 2014;24:1109-16. [Crossref] [PubMed]
48. Noel P, Schneck AS, Nedelcu M, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases. Surg Obes Relat Dis 2014;10:1116-22. [Crossref] [PubMed]
49. Gibson SC, Le Page PA, Taylor CJ. Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon Australian practice. ANZ J Surg 2015;85:673-7. [Crossref] [PubMed]
50. Moon RC, Shah N, Teixeira AF, et al. Management of staple line leaks following sleeve gastrectomy. Surg Obes Relat Dis 2015;11:54-9. [Crossref] [PubMed]
51. Juza RM, Haluck RS, Pauli EM, et al. Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management. Surg Obes Relat Dis 2015;11:60-4. [Crossref] [PubMed]
52. Guetta O, Ovnat A, Shaked G, et al. Analysis of Morbidity Data of 308 Cases of Laparoscopic Sleeve Gastrectomy--the Soroka Experience. Obes Surg 2015;25:2100-5. [Crossref] [PubMed]
53. Vix M, Diana M, Marx L, et al. Management of staple line leaks after sleeve gastrectomy in a consecutive series of 378 patients. Surg Laparosc Endosc Percutan Tech 2015;25:89-93. [Crossref] [PubMed]
54. Cal P, Deluca L, Jakob T, et al. Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial. Surg Endosc 2016;30:1812-5. [Crossref] [PubMed]
55. Casella G, Soricelli E, Giannotti D, et al. Long-term results after laparoscopic sleeve gastrectomy in a large monocentric series. Surg Obes Relat Dis 2016;12:757-62. [Crossref] [PubMed]
56. Praveenraj P, Gomes RM, Kumar S, et al. Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm. J Minim Access Surg 2016;12:342-9. [Crossref] [PubMed]
57. Musella M, Milone M, Bianco P, et al. Acute Leaks Following Laparoscopic Sleeve Gastrectomy: Early Surgical Repair According to a Management Algorithm. J Laparoendosc Adv Surg Tech A 2016;26:85-91. [Crossref] [PubMed]
58. Alvarenga ES, Lo Menzo E, Szomstein S, et al. Safety and efficacy of 1020 consecutive laparoscopic sleeve gastrectomies performed as a primary treatment modality for morbid obesity. A single-center experience from the metabolic and bariatric surgical accreditation quality and improvement program. Surg Endosc 2016;30:2673-8. [Crossref] [PubMed]
59. Garg H, Aggarwal S, Misra MC, et al. Mid to long term outcomes of Laparoscopic Sleeve Gastrectomy in Indian population: 3-7 year results - A retrospective cohort study. Int J Surg 2017;48:201-9. [Crossref] [PubMed]
60. Nocca D, Loureiro M, Skalli EM, et al. Five-year results of laparoscopic sleeve gastrectomy for the treatment of severe obesity. Surg Endosc 2017;31:3251-7. [Crossref] [PubMed]
61. Boeker C, Mall J, Reetz C, et al. Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height-an Observational Cohort Study: Fundus Wall Thickness and Leaks. Obes Surg 2017;27:3209-14. [Crossref] [PubMed]
62. Al Jarallah M, Kassir R, El-Barbari M, et al. Three-Year Follow-Up of Laparoscopic Reduced Port Sleeve Gastrectomy in 808 Consecutive Patients. Obes Surg 2017;27:2643-8. [Crossref] [PubMed]
63. Montuori M, Benavoli D, D'Ugo S, et al. Integrated Approaches for the Management of Staple Line Leaks following Sleeve Gastrectomy. J Obes 2017;2017:4703236. [Crossref] [PubMed]
64. Benedix F, Poranzke O, Adolf D, et al. Staple Line Leak After Primary Sleeve Gastrectomy-Risk Factors and Mid-term Results: Do Patients Still Benefit from the Weight Loss Procedure? Obes Surg 2017;27:1780-8. [Crossref] [PubMed]
65. Sepúlveda M, Astorga C, Hermosilla JP, et al. Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases. Obes Surg 2017;27:1474-80. [Crossref] [PubMed]
66. Coskun H, Yardimci E. Effects and results of fibrin sealant use in 1000 laparoscopic sleeve gastrectomy cases. Surg Endosc 2017;31:2174-9. [Crossref] [PubMed]
67. Moloney BM, Hynes DA, Kelly ME, et al. The role of laparoscopic sleeve gastrectomy as a treatment for morbid obesity; review of outcomes. Ir J Med Sci 2017;186:143-9. [Crossref] [PubMed]
68. Doumouras AG, Saleh F, Anvari S, et al. Mastery in Bariatric Surgery: The Long-term Surgeon Learning Curve of Roux-en-Y Gastric Bypass. Ann Surg 2018;267:489-94. [Crossref] [PubMed]
69. Singla V, Aggarwal S, Garg H, et al. Outcomes in Super Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2018;28:256-62. [Crossref] [PubMed]
70. Lynn W, Ilczyszyn A, Aguilo R, et al. Standardised Sleeve Gastrectomy Without Reinforcement. JSLS 2018;22:e2018.00015.
71. Siddiq G, Aziz W. Laparoscopic Sleeve Gastrectomy: To Suture or not to Suture Staple Line? Cureus 2018;10:e2992. [Crossref] [PubMed]
72. Usta S, Karabulut K. Effect of fibrin glue or suture on leakage in patients undergoing laparoscopic sleeve gastrectomy. Niger J Clin Pract 2018;21:1209-12. [Crossref] [PubMed]
73. Currò G, Komaei I, Lazzara C, et al. Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity. Surg Technol Int 2018;33:111-8. [PubMed]
74. Inaba CS, Koh CY, Sujatha-Bhaskar S, et al. One-Year Mortality after Contemporary Laparoscopic Bariatric Surgery: An Analysis of the Bariatric Outcomes Longitudinal Database. J Am Coll Surg 2018;226:1166-74. [Crossref] [PubMed]
75. Hany M, Ibrahim M. Comparison Between Stable Line Reinforcement by Barbed Suture and Non-reinforcement in Sleeve Gastrectomy: a Randomized Prospective Controlled Study. Obes Surg 2018;28:2157-64. [Crossref] [PubMed]
76. Cesana G, Cioffi S, Giorgi R, et al. Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1738 Consecutive Procedures. Obes Surg 2018;28:627-35. [Crossref] [PubMed]
77. Taha O, Abdelaal M, Talaat M, et al. A Randomized Comparison Between Staple-Line Oversewing Versus No Reinforcement During Laparoscopic Vertical Sleeve Gastrectomy. Obes Surg 2018;28:218-25. [Crossref] [PubMed]
78. Hans PK, Guan W, Lin S, et al. Long-term outcome of laparoscopic sleeve gastrectomy from a single center in mainland China. Asian J Surg 2018;41:285-90. [Crossref] [PubMed]
79. Castagneto Gissey L, Casella Mariolo JR, Genco A, et al. 10-year follow-up after laparoscopic sleeve gastrectomy: Outcomes in a monocentric series. Surg Obes Relat Dis 2018;14:1480-7. [Crossref] [PubMed]
80. Boru CE, Angelis F, Iossa A, et al. Persistent Fistula after Sleeve Gastrectomy: A Chronic Dilemma. Chirurgia (Bucur) 2019;114:790-7. [Crossref] [PubMed]
81. AlKhaldi LK, AlSaffar NA, AlHamdan F, et al. Long-term outcomes after laparoscopic sleeve gastrectomy in Kuwait. Ann Saudi Med 2019;39:100-3. [Crossref] [PubMed]
82. Giuliani A, Romano L, Marchese M, et al. Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review. Surg Obes Relat Dis 2019;15:1414-9. [Crossref] [PubMed]
83. Bashah M, Khidir N, El-Matbouly M. Management of leak after sleeve gastrectomy: outcomes of 73 cases, treatment algorithm and predictors of resolution. Obes Surg 2020;30:515-20. [Crossref] [PubMed]
84. Olmi S, Cesana G, Rubicondo C, et al. Management of 69 Gastric Leakages after 4294 Consecutive Sleeve: The Experience of a High Volume Bariatric Center. Obes Surg 2020;30:3084-92. [Crossref] [PubMed]
85. Angrisani L, Santonicola A, Iovino P, et al. Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters. Obes Surg 2021;31:1937-48. [Crossref] [PubMed]
86. Felsenreich DM, Bichler C, Langer FB, et al. Sleeve Gastrectomy: Surgical Technique, Outcomes, and Complications. Surg Technol Int 2020;36:63-9. [PubMed]
87. Genco A, Castagneto-Gissey L, Lorenzo M, et al. Esophageal adenocarcinoma after sleeve gastrectomy: actual or potential threat? Italian series and literature review. Surg Obes Relat Dis 2021;17:848-54. [Crossref] [PubMed]
88. Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review. Surg Endosc 2020;34:396-407. [Crossref] [PubMed]
89. Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369:1434-42. [Crossref] [PubMed]
90. Gil PJ, Ruiz-Manzanera JJ, Ruiz de Angulo D, et al. Learning Curve for Laparoscopic Sleeve Gastrectomy: a Cumulative Summation (CUSUM) Analysis. Obes Surg 2022;32:2598-604. [Crossref] [PubMed]
91. Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis 2016;12:750-6. [Crossref] [PubMed]
92. Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg 2004;14:1290-8. [Crossref] [PubMed]
93. Chen B, Kiriakopoulos A, Tsakayannis D, et al. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg 2009;19:166-72. [Crossref] [PubMed]
94. Parikh M, Issa R, McCrillis A, et al. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257:231-7. [Crossref] [PubMed]
95. Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review. Surg Endosc 2020;34:396-407. [Crossref] [PubMed]