1. Luigi Angrisani Director - General and Endoscopic Surgery Unit S.Giovanni Bosco Hospital, Naples, Italy LINEE GUIDA PER IL RINFORZO DELLE SUTURE IN CHIRURGIA BARIATRICA Leakage/fistole e sanguinamento dalle linee di sutura: siti ed incidenza

2. “S.GIOVANNI BOSCO” EXPERIENCE N=1109 Pts Angrisani 2013

3. Leak is reported in 1-7 % of patients

5. Prevention 1)Not too tight sleeve (using larger bougies ≥ 40fr)* 2)Firing the stapler lateral to the angle of His 3)Performing an intraoperative leak test * * Leak rate 1.5% (75% GE junction)

7. Conclusions Mean leak rate 2.4% (range 0-7%) 92% at the GE junction 79% of leaks occurred more than 10 days postoperatively Super-obese pts leak rate 2.9% vs morbid obese patients leak rate 2.2% (not significant p>0.05) Stricture rate: 0.5% Bleeding rate: 0.7% Boogie size of <40Fr is associated with increased risk of leak Oversewing or buttressing of the staple line does not have a clinically significant effect on leaks Aurora A et al. Surg Endosc (2012) 26:1509-1515)

9. Techniques used for LSG

10. Effect of technique on leak rate Overall leak rate: 2.2%

15. Conclusions 1)Leak rate of approximately 2.4% 2)Clinically significant bleeding and stricture rate of less than 1% 3)Leak at GE junction 89% 4)Greater risk of leak in BMI > 50 kg/m 2 5)Greater risk of leak with smaller bougies (<40 Fr) 6)Oversewing or buttressing of the staple line does not have a clinically significant effect on leak

16. ANGRISANI 2013 Naples, Italy

17. RESULTS Complications: intraoperative leaks in SG pts N=2/495 (0,4%) Intra-Operative conversion to: 1 pt*1pt Roux-en-Y GBP with Distal Stomach Preservation Roux en Y limb with Sub-Total Gastrectomy * Band removal 1 year before ANGRISANI 2013 Naples, Italy

21. Leak rate: 17/1133 (1.5%)

23. p value: not statistically significant

24. Mortality1 (0,2%)Mortality1 (0,2%) Laparotomic Conversion4 (0.8%)Laparotomic Conversion4 (0.8%) Gastro-jejunal Leak2 (0,4%)Gastro-jejunal Leak2 (0,4%) Gastro-jejunal Stenosis3 (0,6%)Gastro-jejunal Stenosis3 (0,6%) Mean Operative Time 140  25 minMean Operative Time 140  25 min Hospital Stay 5  2 daysHospital Stay 5  2 days Laparoscopic Roux en Y Gastric Bypass N=510 (Jan 2000 – Dec 2012) General and Endoscopic Surgery Unit “S. Giovanni Bosco” Hospital - Naples - Italy Director: Luigi Angrisani

25. Laparoscopic Roux en Y Gastric Bypass REOPERATIONS 22/510 (4.3%) Jan 00- Dec 12 Internal herniaN=11 Bowel perforation N=3 Jejuno-jejunostomy stenosis N=2 Bowel obstruction / Adhesions N=2 IntussusceptionN=2 HemoperitoneumN=1 Protein malnutrition N=1 General and Endoscopic Surgery Unit “S. Giovanni Bosco” Hospital - Naples - Italy Director: Luigi Angrisani

26. CONCLUSIONS The healing time of a SG leak is longer than GBPs’ leak Even if the rate of complications of GBP & SG is similar, those after SG appear to have a worse outcome leading to more aggressive procedures (Total/distal gastrectomy) Revisional procedures have an increased risk of leak versus primary procedures. Angrisani-Formisano 2013