title: Does tissue ischemia actually contribute to leak after sleeve gastrectomy? An experimental study.
abstract: BACKGROUND
  Staple line leak, although rare, is among the most common postoperative complications after sleeve gastrectomy (SG) and usually occurs in the gastroesophageal (GE) junction. Increased intragastric pressure, regional ischemia, and technical failure of stapling devices have been reported as the main risk factors of postoperative leak. The aim of this study was to evaluate the impact of ischemia and intraluminal pressure in leak appearance.
  
  
  METHODS
  Landrace swine (n = 12) were subjected to SG and total gastrectomy subsequently. Lactic acid, glycerol, and pyruvate were measured by microdialysis in GE junction and pylorus before and nine times after operation, and lactate/pyruvate (L/P) ratio was calculated as well. Moreover, ex vivo air was insufflated inside the tubularized stomach till a rupture of the staple line occurs. Maximum air pressure reached and location of rupture were recorded.
  
  
  RESULTS
  Increase of lactic acid and L/P ratio were demonstrated in GE junction measurements; however, when the measurements between GE junction and pylorus were compared, no statistically significant differences were found, with the exception of a slightly increased lactate concentration in pylorus in the midst of measurements. The maximum air pressure recorded varied from 3 to 75 mmHg (mean 24.5 mmHg) and the majority of ruptures (n = 8) occurred in GE junction. In one of them, clip displacement was noticed.
  
  
  CONCLUSIONS
  No evidence of increased ischemia in GE junction compared to pylorus was recorded. Increased intraluminal pressure and stapling malfunction may play the most important role in leak appearance.
authors.affiliation: First Department of Propaedeutic Surgery, Hippokration Hospital, Athens Medical School Greece, 114 Queen's Sofia Avenue, Athens, Greece.
authors.forename: Maria
authors.initials: M
authors.lastname: Natoudi
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Theodorou
authors.forename: Apostolos
authors.initials: A
authors.lastname: Papalois
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Drymousis
authors.forename: Leonidas
authors.initials: L
authors.lastname: Alevizos
authors.forename: Stylianos
authors.initials: S
authors.lastname: Katsaragakis
authors.forename: Georgios
authors.initials: G
authors.lastname: Zografos
authors.forename: Emmanouel
authors.initials: E
authors.lastname: Leandros
authors.forename: Evangelos
authors.initials: E
authors.lastname: Menenakos
mesh_terms: D057868:Anastomotic Leak / Q000209:etiology / Q000378:metabolism / Q000473:pathology*; D000818:Animals; D004943:Esophagogastric Junction / Q000473:pathology*; D005743:Gastrectomy / Q000009:adverse effects / Q000379:methods*; D005990:Glycerol / Q000378:metabolism; D019344:Lactic Acid / Q000378:metabolism; D017551:Microdialysis; D019289:Pyruvic Acid / Q000378:metabolism; D017792:Surgical Stapling / Q000009:adverse effects / Q000379:methods*; D013529:Surgical Wound Dehiscence / Q000473:pathology*; D013552:Swine
chemical_list: D019344:Lactic Acid; D019289:Pyruvic Acid; D005990:Glycerol