title: Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences.
abstract: BACKGROUND
  Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause.
  
  
  METHODS
  The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks.
  
  
  RESULTS
  Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41-3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures.
  
  
  CONCLUSIONS
  There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.
authors.affiliation: Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China.
authors.forename: Bo
authors.initials: B
authors.lastname: Chen
authors.affiliation: First Surgical Clinic, Department of Surgery, ''Hygeia'' Hospital, Athens, Greece.
authors.forename: Andreas
authors.initials: A
authors.lastname: Kiriakopoulos
authors.affiliation: First Surgical Clinic, Department of Surgery, ''Hygeia'' Hospital, Athens, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Tsakayannis
authors.affiliation: Department of Pathology, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
authors.forename: Mitchell S
authors.initials: MS
authors.lastname: Wachtel
authors.affiliation: First Surgical Clinic, Department of Surgery, ''Hygeia'' Hospital, Athens, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Linos
authors.affiliation: Department of Surgery, University of Alabama, VAMC Surgical Service 112, 700 19th Street South, Birmingham, AL, 35233, USA. eldo.frezza@ccc.uab.edu.
authors.forename: Eldo E
authors.initials: EE
authors.lastname: Frezza
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D017792:Surgical Stapling / Q000009:adverse effects*; D013529:Surgical Wound Dehiscence / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome; D055815:Young Adult
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