title: Gastric Wall Thickness and the Choice of Linear Staples in Laparoscopic Sleeve Gastrectomy: Challenging Conventional Concepts.
abstract: 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/m2. 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.
authors.affiliation: Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel.|Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Yasmin
authors.initials: Y
authors.lastname: Abu-Ghanem
authors.affiliation: Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel.|Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Chanan
authors.initials: C
authors.lastname: Meydan
authors.affiliation: Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel.|Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Lior
authors.initials: L
authors.lastname: Segev
authors.affiliation: Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel.|Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.|Herzliya Medical Center, 7 Ramat Yam St, 4685107, Herzliya, Israel.
authors.forename: Moshe
authors.initials: M
authors.lastname: Rubin
authors.affiliation: Center for Disease Control, Ministry of Health, Jerusalem, Israel.
authors.forename: Orit
authors.initials: O
authors.lastname: Blumenfeld
authors.affiliation: Department of Surgery, Tel HaShomer Medical Center, Ramat Gan, Israel. hadarspivak@gmail.com.|Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. hadarspivak@gmail.com.|Herzliya Medical Center, 7 Ramat Yam St, 4685107, Herzliya, Israel. hadarspivak@gmail.com.
authors.forename: Hadar
authors.identifier: 0000-0003-1188-8052
authors.initials: H
authors.lastname: Spivak
mesh_terms: D000328:Adult; D015992:Body Mass Index; D005240:Feasibility Studies; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D005748:Gastric Fundus / Q000601:surgery; D006488:Hemostasis, Surgical / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000473:pathology / Q000601:surgery*; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000517:prevention & control; D013270:Stomach / Q000473:pathology* / Q000601:surgery; D017792:Surgical Stapling / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D013537:Sutures
keywords: Closed staple height; Gastric wall thickness; Laparoscopic sleeve gastrectomy; Reloads; Stapler