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"Inverted Corner" for sleeve gastrectomy

Milton Owens, M.D.C.M., John Sczepaniak, B.S., Arash Mahdavi, D.O.

Sleeve gastrectomy is an appealing weight loss operation. Patients lose approximately 60% of their excess weight in 1year [1], and weight regain, which is a complication of all procedures, is amenable to a variety of different surgical approaches [2,3]. Moreover, long-term complications, such as bowel obstruction, iron deficiency, and marginal ulcer after gastric bypass or erosion or slippage after adjustable gastric banding, seem unlikely or impossible. Leakage after sleeve gastrectomy occurs in approximately 2% of cases [4,5] and is difficult to treat [6,7]. Heartburn, affecting 25–40% of patients after surgery, is a lesser, but clearly troublesome, side effect of sleeve surgery [7]. We have developed a modification to the usual surgical technique that we believe minimizes both leaks and heartburn.
Approximately 3 of 4 leaks developing after sleeve gastrectomy occur near the gastroesophageal junction [7,8]. The suggested causes include the relative thinness of the stomach wall near the esophagus [9] and the potential for distal obstruction, particularly near the “crow’s foot” [8]. It has been suggested that the gastric transection and staple line should be completed a short distance lateral to the gastroesophageal junction to reduce the occurrence of a leak (Fig. 1) [8,10]. However, this means increasing the sleeve diameter in that area and, according to La Place’s law, the tension on the wall is also increased and, by implication,the likelihood of a blowout and leakage is also increased. We have managed this problem by inverting the corner and sleeve for a length of 2 or 3 in., thereby doubling the thickness of the closure and narrowing the sleeve relative to its more distal diameter (Fig. 2). Because some of the blood supply to the stomach at the left gastroesophageal junction is through the fat pad at that location, we have left it intact whenever the necessity for adequate exposure permitted.
We create our sleeve alongside a 38F bougie and remove the bougie when we are inverting the corner and then reintroduce the bougie afterward to be confident of patency. Weinvert with a running 2-0 Prolene suture (Ethicon Endo-Surgery, Somerville, NJ) and then oversew the inversion with a second running suture to ensure that the “corner” does not slip out between stitches at some later time (Video 1). On radiography, the narrowing appears maximal just below the gastroesophageal junction (Fig. 3). We have had no leaks since initiating this technique, and we have also noted a much reduced incidence of heartburn. Dysphagia from the narrowing produced has not been common and, when present, has been transitory and responsive to hyoscyamine sublingual tablets.

References

[1] ASMBS updated position statement on sleeve gastrectomy as a bariatric
procedure. Surg Obes Relat Dis 2010;6:1–5.
[2] Morales MP, Wheeler AA, Ramaswamy A, Scott JS, de la Torre RA.
Laparoscopic revisional surgery after Roux-en-Y gastric bypass and
sleeve gastrectomy. Surg Obes Relat Dis 2010t;6:485–90.
[3] Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D,
Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve
gastrectomy: a feasibility study. Obes Surg 2011;21:832–5.
[4] Abdemur A, Fendrich I, Rosenthal R. Laparoscopic conversion of laparoscopic
sleeve gastrectomy to gastric bypass for intractable gastroesophageal
reflux disease. Surg Obes Relat Dis Epub 2011 June 17.
[5] Akkary E, Duffy A, Bell R. Deciphering the sleeve: technique,
indications, efficacy, and safety of sleeve gastrectomy. Obes Surg
2008;18:1323–9.
[6] Márquez MF, Ayza MF, Lozano RB, Morales Mdel M, Díez JM,
Poujoulet RB. Gastric leak after laparoscopic sleeve gastrectomy.
Obes Surg 2010;20:1306 –11.
[7] Deitel M, Gagner M, Erickson AL, Crosby RD. Third International
Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis
2011;7:749 –59.
[8] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of
leak: a systematic analysis of 4,888 patients. Surg Endosc Epub 2011
Dec 7.
[9] Elariny H, González H, Wang B. Tissue thickness of human stomach
measured on excised gastric specimens from obese patients. Surg
Technol Int 2005;14:119 –24.
[10] Bellanger DE, Greenway FL. Laparoscopic sleeve gastrectomy, 529
cases without a leak: short-term results and technical considerations.
Obes Surg 2011;21:146 –50.