Objectives: To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables. Summary of Background Data: Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. Methods: From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. Results: A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (k ¼ 0.85, P < 0.001). There were 59 patients, (training: 30, validation: 29). Age 42.5 AE 10.8 versus 38.9 AE 10.0 years (P ¼ 0.187); female 65.5% versus 80.0% (P ¼ 0.211), weight 127.4 AE 31.3 versus 141.0 AE 47.9 kg, (P ¼ 0.203). In the training group, there was a trend toward longer hospital stays as grading increased (I ¼ 10.5 d; II ¼ 24 d; III ¼ 66.5 d; IV ¼ 72 d; P ¼ 0.005). Risk of salvage resection increased (risk ratio grade 4 ¼ 9; P ¼ 0.043) as did complication severity (P ¼ 0.027).Findings were reproduced in the validation group: risk of salvage resection (P ¼ 0.007), hospital stay (P ¼ 0.001), complications (P ¼ 0.016). Conclusion:We have developed and validated a classification system, based on protocolized CT imaging that predicts a step-wise increased risk of salvage resection, complication severity, and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions.
Purpose Staple line leak following sleeve gastrectomy is a significant problem and has been hypothesised to be related to hyperpressurisation in the proximal stomach. There is, however, little objective evidence demonstrating how these forces could be transmitted to the luminal wall. We aimed to define conditions in the proximal stomach and simulate the transmission of stress forces in the post-operative stomach using a finite element analysis (FEA). Materials and Methods The manometry of fourteen patients post sleeve gastrectomy was compared to ten controls. Manometry, boundary conditions, and volumetric CT were integrated to develop six models. These models delineated luminal wall stress in the proximal stomach. Key features were then varied to establish the influence of each factor. Results The sleeve gastrectomy cohort had a significantly higher peak intragastric isobaric pressures 31.58 ± 2.1 vs. 13.49 ± 1.3 mmHg (p = 0.0002). Regions of stress were clustered at the staple line near the GOJ, and peak stress was observed there in 67% of models. A uniform greater curvature did not fail or concentrate stress under maximal pressurisation. Geometric variation demonstrated that a larger triangulated apex increased stress by 17% (255 kPa versus 218 kPa), with a 37% increase at the GOJ (203kPA versus 148kPA). A wider incisura reduced stress at the GOJ by 9.9% (128 kPa versus 142 kPa). Conclusion High pressure events can occur in the proximal stomach after sleeve gastrectomy. Simulations suggest that these events preferentially concentrate stress forces near the GOJ. This study simulates how high-pressure events could translate stress to the luminal wall and precipitate leak. Graphical Abstract
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