Letters to the Editor Annals of Surgery Volume 267, Number 3, March 2018 11. Giglio MC, Spalding DR, Giakoustidis A, et al. other hemostatic clips or agents) that could represent. Four out of 5 MBSAQIP surgeons Meta-analysis of drain amylase content on post- impact leaks and bleeds. Adequacy of fundus use SLR at some point, and if the conclusions operative day 1 as a predictor of pancreatic fistula resection, stapler type, stapler cartridge are read as they are, will affect the majority of following pancreatic resection. Br J Surg. 2016;103:328–336. selection, how close resection is to the cardia, the surgeons’ technique. Many of them will 12. Kawai M, Tani M, Terasawa H, et al. Early removal whether a crural repair was done are a partial be managing staple line bleeding in different of prophylactic drains reduces the risk of intra- list of numerous other technical aspects of the ways adding potential factors that can affect abdominal infections in patients with pancreatic procedure that are not assessed. The lack of outcomes. Also healthcare facilities may head resection: prospective study for 104 consecu- granular information including the type of force surgeons to change their comfort zone tive patients. Ann Surg. 2006;244:1–7. Staple Line Reinforcement (SLR) or stapler technique without addressing the variables 13. Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resec- limits the conclusions that can be drawn from not studied in the present article. The readers tions: results of a prospective randomized trial. this study. Knowing these extensive vari- and public should be cautious about using the Ann Surg. 2010;252:207–214. ations not accounted and limitations I wanted incomplete data to dictate health care policy to share my concern about the strong state- and patient care. ment in your conclusions: ‘‘SLR is associated Disclosure: The author has received with increased leak rates.’’ As you clearly from Reshape Medical, consultant and Impact of Different elaborate in your description of the limita- speaker fees and research support for FDA tions and further state that the conclusions Surgical Techniques on clinical study; from USGI Medical, consult- can be affected by specifics not analyzed ant fees and research support for FDA (like type of reinforcement, type of over Outcomes in Laparoscopic clinical study; from Obalon, research support sewing, etc), I cannot understand the strong for FDA clinical study; from Olympus, con- Sleeve Gastrectomies: First statement without further add to the con- sultant and speaker fees; from Gore, consult- clusions possible something like: ‘‘the data Report from the Metabolic ant and speaker fees; from Ethicon Endo- suggest that there has to be further investi- Surgery, consultant fees. The author declares and Bariatric Surgery gation on what factors or variables are associ- no conflicts of interest. ated to more leaks in cases using SLR.’’ Accreditation and Quality The 2 most commonly used types of Jaime Ponce, MD, FACS, FASMBS reinforcement available on the market during Improvement Program Chattanooga, TN the study period are very different in material email@example.com (MBSAQIP) composition and clinical data supporting its efficacy. The most common used reinforce- ment is a bio absorbable synthetic made out REFERENCES To the Editor: of polyglycolic acid and trimethylene 1. Berger ER, Clements RH, Morton JM, et al. The he Metabolic and Bariatric Surgery carbonate, and is an average of 0.4 mm thick impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies. The first report T Accreditation and Quality Improvement when used on both the anvil and cartridge from the Metabolic and Bariatric Surgery Accred- Program (MBSAQIP) developed as a joint side of the stapler. This is quite different than itation and Quality Improvement Program (MBSA- venture by the American College of Surgeons the second most common used reinforcement QIP). Ann Surg. 2016;264:464–473. and the American Society for Metabolic and that is made out of bovine pericardium 2. Gagner M, Buchwald JN. Comparison of laparo- Bariatric Surgery have produced the largest material and is an average of 0.8 to 1.2 mm scopic sleeve gastrectomy leak rates in four staple- line reinforcement options: a systematic review. in total thickness. As Berger et al database in bariatric surgery. The authors of mentioned 1 Surg Obes Relat Dis. 2014;10:713–723. the article should be congratulated for in the article, ‘‘at the staple line intersections 3. Gagner M, Brown M. Update on sleeve gastrec- organizing, compiling, and analyzing the the staple line reinforcement material may be tomy leak rate with the use of reinforcement. Obes largest sleeve gastrectomy registry, a signifi- stacked into 4 layers, so you would expect Surg. 2016;26:146–150. cant accomplishment for all the individuals that thickness of the reinforcement material that contributed. This is strong evidence that being used may play a role in the staple in general accredited centers surgeons are formation and durability.’’ ahead of the learning curve, experiencing When analyzing the differences in 2 Half the Truth is Often a less than 1% leaks after the most common reinforcement types, Gagner et al looked at bariatric operation performed nowadays. the leak rates for these 2 reinforcement types Great Lie: Over a Hundred Great accomplishment considering that there and found that the leak rate is significantly less Years of Controversy on are publications with higher leak rates, bleed- when absorbable reinforcement is used com- ing rates, and overall morbidity. pared to bovine pericardium (1.09% vs 3.30%, Pancreatic Fistula Between I would like to acknowledge the P ¼ 0.0006). In addition, a recent follow up limitations of this study and database clearly study done by Gagner et al, found that the Pancreaticogastrostomy stated by the authors, which include the fact updated leak rate for absorbable reinforcement and that there is significant intraoperative vari- to be 0.67%. This example shows that with ation in technique and experience of the such differences between the leak rates of SLR Pancreaticojejunostomy surgeon that is not captured and could con- types, the additional details around the type of After Pancreaticodu- tribute to the outcomes of the patients (ie, reinforcement used is needed before making how close the stapler is actually applied to the general conclusions as a whole. odenectomy bougie is unknown and could alter sleeve In conclusion, the MBSAQIP database size). The specific techniques of over sewing is a large data set that may be used to analyze To the Editor: were not recorded in detail. There are many clinical questions. However, without additional surgical techniques (ie, buttressing digging into the details of the data one may e have read the recently published of the omentum to the staple line or use of miss the true meaning of what the data could W article with great interests by Keck e52 | www.annalsofsurgery.com 2017 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery – Wolters Kluwer Health
Published: Mar 1, 2018
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