|Year : 2023 | Volume
| Issue : 2 | Page : 79-84
A Delphi consensus on the surgical technique of laparoscopic sleeve gastrectomy: An obesity and metabolic surgery society of India initiative
Aparna Govil Bhasker1, Om Tantia2, Manish Khaitan3, Randeep Wadhawan4, KS Kular5, Sarfaraz Jalil Baig6, Sumeet Shah7, Vivek Bindal8, Ashish Vashishtha9, Atul N. C. Peters10, Deep Goel11, Mahendra Narwaria12, Manish Baijal13, Nandakishore Dukkipati14, Pradeep Chowbey15, Rajesh Bhojwani16, Ramen Goel17, Sandeep Aggarwal18, Sanjay Borude19, Sanjay Patolia20, Shashank Shah21, Shrihari Dhorepatil22, Sreejoy Patnaik23, Sudhir Kalhan24, Surendra Ugale25, Praveen Raj Palanivelu26
1 Saifee Hospital, Mumbai, India
2 ILS Hospital, Kolkata, India
3 KD Hospital, Ahmedabad, India
4 Manipal Hospital, New Delhi, India
5 Kular Jospital, Bija, Punjab, India
6 Belle Vue Hospital, Kolkata, West Bengal, India
7 PSRI Hospital, Delhi, India
8 Max Hospital, Delhi, India
9 Department of General Surgery & Robotics, Bariatric & Robotic Surgeon, Max Superspeciality Hospital, Saket, New Delhi, India
10 Max Smart Superspecialty Hospital, Saket, Delhi, India
11 Max-BLK Super Specialty Hospital, New Delhi, India
12 Asian Bariatric Pvt. Ltd, Ahmedabad, Gujarat, India
13 Max Institute of Laparoscopic, Endoscopic and Bariatric Surgery, Hyderabad, India
14 LivLife Hospital, Hyderabad, India
15 Max Healthcare, New Delhi, India
16 Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India
17 Wockhardt Hospital, Mumbai, India
18 All India Institute of Medical Sciences, New Delhi, India
19 Breach Candy Hospital, Mumbai, India
20 Asian Bariatrics, Ahmedabad, India
21 Laparo-obeso Center, Pune, India
22 Shree Hospital, Pune, Maharashtra, India
23 Shanti Memorial Hospital, Cuttack, India
24 Gangaram Hospital, Delhi, India
25 Kirloskar Hospital, Hyderabad, India
26 Gem Hospital, Coimbatore, India
|Date of Submission||13-Apr-2023|
|Date of Acceptance||01-Jun-2023|
|Date of Web Publication||28-Jul-2023|
Aparna Govil Bhasker
Saifee Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic sleeve gastrectomy (LSG) is the commonest bariatric operation being performed in India and worldwide. There are many technical variations that are being practiced. This Delphi consensus was an Obesity and Metabolic Surgery Society of India (OSSI) initiative to standardize the surgical technique of LSG. Methods: Twenty bariatric surgeons were selected as experts based on their years of experience in LSG, overall patient volumes, publications, and the recommendations of the executive committee of OSSI, to vote on 26 statements regarding the surgical steps of LSG. The minimum cutoff for consensus was taken as 70%. Results: The committee achieved a consensus on 19 out of 26 statements in the first round. One question was sent for reconsideration and 3 were resent after modification. Finally, consensus was reached on 22 statements. The consensus was reached regarding the use of preoperative upper gastrointestinal endoscopy. 85.7% agreed on an antral length of 3–5 cm. 85.7% were in favor of dissecting the left crus of the diaphragm completely and 100% agreed on Roux-en y gastric bypass to be the procedure of choice in the presence of medically refractory gastroesophageal reflux disease with hiatus hernia. Most experts agreed that a calibration tube must be used during LSG and the recommended size was between 36 and 40 Fr. Ninety-five percent agreed that care must be taken to avoid narrowing at the incisura and also to stay away from the angle of His. 71.4% did not recommend any kind of staple line reinforcement and 71.4% recommended a postoperative leak test. Conclusion: This Delphi consensus is a step toward improving the quality of surgical outcomes of LSG in India. This document has attempted to establish technical specifications of performing LSG. This will in turn help to maximize the reliability, standardization, and safety of the procedure until more robust studies are published.
Keywords: Antral length, bougie size, Delphi consensus, gastroesophageal reflux disease, sleeve gastrectomy, techniques
|How to cite this article:|
Bhasker AG, Tantia O, Khaitan M, Wadhawan R, Kular K S, Baig SJ, Shah S, Bindal V, Vashishtha A, Peters AN, Goel D, Narwaria M, Baijal M, Dukkipati N, Chowbey P, Bhojwani R, Goel R, Aggarwal S, Borude S, Patolia S, Shah S, Dhorepatil S, Patnaik S, Kalhan S, Ugale S, Palanivelu PR. A Delphi consensus on the surgical technique of laparoscopic sleeve gastrectomy: An obesity and metabolic surgery society of India initiative. J Bariatr Surg 2023;2:79-84
|How to cite this URL:|
Bhasker AG, Tantia O, Khaitan M, Wadhawan R, Kular K S, Baig SJ, Shah S, Bindal V, Vashishtha A, Peters AN, Goel D, Narwaria M, Baijal M, Dukkipati N, Chowbey P, Bhojwani R, Goel R, Aggarwal S, Borude S, Patolia S, Shah S, Dhorepatil S, Patnaik S, Kalhan S, Ugale S, Palanivelu PR. A Delphi consensus on the surgical technique of laparoscopic sleeve gastrectomy: An obesity and metabolic surgery society of India initiative. J Bariatr Surg [serial online] 2023 [cited 2023 Sep 29];2:79-84. Available from: http://www.jbsonline.org/text.asp?2023/2/2/79/382481
| Introduction|| |
It has been forecasted that by the year 2040, the prevalence of overweight individuals will double and that of obesity will triple in India. This rapid increase has led to growing acceptance of bariatric surgery in the population. At present bariatric surgery remains the only effective treatment option for people living with clinically severe obesity. Over the years, there has been an increased interest amongst surgeons to take up bariatric surgery as a subspecialization.
Standardization is the way forward for every maturing specialty and with rising numbers of bariatric procedures; it has become the need of the hour. The WHO has defined standardization as “the process of developing, agreeing on and implementing uniform technical specifications, criteria, methods, processes, designs or practices that can increase compatibility, interoperability, safety, repeatability, and quality.” Standardization is important to accurately assess future outcomes, facilitate the training of aspiring surgeons and has an impact on future policy decisions.
Laparoscopic sleeve gastrectomy (LSG) is the commonest bariatric operation performed across the world and constitutes 46% of all bariatric procedures. The perceived simplicity of its surgical technique as compared to other bariatric operations is one of the causes for its popularity amongst surgeons. Despite the global popularity, there is still a lack of absolute clarity regarding the surgical steps of LSG. As LSG is also a part of many other sleeve-plus procedures, it is imperative to have some kind of standardization in place. To this effect, a Delphi consensus was initiated by the Obesity and Metabolic Surgery Society of India (OSSI). The Delphi method is a commonly used method to reach a consensus for key steps of multiple surgical procedures. This article presents the findings of the Delphi consensus conducted by OSSI.
| Methods|| |
OSSI conducted Delphi consensus on the technical aspects of Roux-en y gastric bypass, sleeve gastrectomy, one anastomosis gastric bypass, bariatric nutrition, and perioperative care. This paper presents the findings of the sleeve consensus. This consensus was based on the Delphi method. OSSI assigned a facilitator to conduct the consensus (AGB). The facilitator prepared the questionnaire, conducted the voting, analyzed the data, and worked on the manuscript. Questions regarding nutrition and peroperative care were not included to avoid repetition as they will be published separately.
Twenty bariatric surgeons were selected as experts based on their years of experience in LSG, overall patient volumes, publications, and the recommendations of the executive committee of OSSI. [Table 1] enlists all the experts included in this study. All identified experts were sent an invitation E-mail regarding the Delphi protocols and to seek their consent for participating in this consensus. Once their consent was obtained, all participants received E-mails with a link to a web-based questionnaire in the form of a Google Survey (https://docs.google.com/forms/d/1933AcZeZ2s5G2Rgq01AJuH35AG1XsFb9nbn5yDYV3Vo/edit). In the first E-mail, participants were asked to choose their response from the multiple choices presented in the survey. Reminders were sent on the 14th and 21st day.
|Table 1: Experts for the laparoscopic sleeve gastrectomy Delphi consensus|
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Any statement that achieved 70% agreement between the participants was taken as consensus.
For statements that did not achieve consensus, a round 2 was initiated once again with the help of a Google survey.https://docs.google.com/forms/d/1w0WQaROZjULlXZeemwSvw_w908f7CSwRvBVCKmMTu7E/edit). In this round, results of the first round were shared along with relevant literature and experts were asked if they would like to revise their response in view of the presented evidence. A 3 weeks' response period was allowed once again for Round 2.
| Results|| |
A 100% response rate was achieved in both the rounds. Consensus flow is shown in [Figure 1].
Consensus was achieved on 22 out of 26 questions. Consensus questions and the responses are listed as under:
- Preferred patient position:
71.4% of the responders operated in either a split leg or lithotomy position. 28.6% of responders preferred to operate in a supine position (consensus achieved)
- Preoperative upper gastrointestinal (UGI) endoscopy must be performed for all patients before LSG (key question):
75% of the responders agreed that a preoperative UGI endoscopy must be performed (consensus achieved)
- Recommended method for entering the abdomen (key question):
65% of surgeons entered the abdomen using a veress needle, 25% through an optical trocar and 10% used whatever the chief surgeon was comfortable with (consensus not achieved)
- Preferred surgeon's position: 66.7% of the experts preferred to stand in between the patient's legs and 33.3% preferred to operate standing on the right side of the patient (consensus not achieved)
- Liver retraction is necessary while performing sleeve gastrectomy (key question):
95.2% experts agreed that liver retraction is necessary while performing LSG (consensus achieved)
- Dissection must begin 3–5 cm proximal to the pylorus while performing LSG (key question):
85.7% of experts agreed that dissection must begin 3–5 cm proximal to the pylorus while performing LSG (consensus achieved)
- The left crus of diaphragm must be completely dissected while performing LSG (key question):
85.7% experts agreed the left crus of diaphragm must be completely dissected while performing LSG (consensus achieved)
- If a moderate to large hiatus hernia is found during LSG, which procedure must be recommended? (key question):
This question elicited a mixed response from the experts initially. It was rephrased and sent again in round 2 as - “best approach for medically refractory gastroesophageal reflux disease (GERD) with hiatus hernia in a patient with obesity”
100% of the experts responded that Roux-en y gastric bypass must be the procedure of choice in such cases (consensus achieved).
- A gastric calibration tube must be routinely used while performing LSG (key question):
95.2% of experts agreed that a gastric carcinoid tumor (GCT) must be routinely used while performing LSG (consensus achieved)
- The recommended size of the GCT must be 36–40 Fr. (key question):
95.2% experts agreed that the recommended size of the GCT must be 36–40 Fr. (consensus achieved)
- GCT must be inserted before the first stapler fire (key question):
76.2% of experts agreed that the GCT must be inserted before the first stapler fire (consensus achieved)
- From which port should the first stapler be fired? (key question):
71.4% of experts recommended that the first stapler fire must be done from the port in the right mid-clavicular line. 23.8% recommended the supra-umbilical port and the remaining from the port in the left mid-clavicular line (consensus achieved)
- First stapler fire must be 3–5 cm proximal to the pylorus (key question):
81% of experts agreed that the first stapler fire must be 3–5 cm proximal to the pylorus (consensus achieved)
- Care must be taken not to narrow the sleeve at the level of the incisura (key question):
95% experts agreed that care must be taken not to narrow the sleeve at the level of the incisura (consensus achieved)
- First stapler fire consists of green cartridge (4.1 mm) or a purple tri-stapler (3–4 mm) cartridge (key question):
This question elicited a mixed response from the experts and a consensus could not be achieved initially. It was rephrased and sent again in round 2 as - “which colour cartridge do you use for the first fire in the antrum while performing LSG?”: 73.7% experts recommended to use green or purple tri-stapler cartridges for the first Fire. 21.1% recommended black tri-stapler cartridge (consensus achieved)
- Second stapler fire consists of blue cartridge (3.5 mm) or a purple tri-stapler (3–4 mm) cartridge (key question):
This question elicited a mixed response from the experts and a consensus could not be achieved initially. It was rephrased and sent again in round 2 as - “which colour cartridge do you use for the second fire in the antrum while performing LSG?”: 57.9% experts recommended using a blue cartridge or a purple tri-stapler cartridge. 31.6% recommended a green or purple tri-stapler cartridge (consensus not achieved)
- Third and subsequent stapler fire consists of a blue cartridge 3.5 mm) or a purple tri-stapler (3–4 mm) cartridge (key question):
This question elicited a mixed response from the experts and a consensus could not be achieved initially. It was rephrased and sent again in round 2 as - “which colour cartridge do you use for the third and subsequent fire in the antrum while performing LSG?”
89.5% experts recommended to use blue or a purple tri-stapler cartridge (consensus achieved).
- Last stapler fire must be 0.5–1 cm lateral to the gastro-esophageal junction (key question):
One hundred percent experts agreed on this (Consensus achieved)
- Hemostasis on the staple line can be achieved by-hemostatic clips, cautery, suturing, or hemostatic sealant solutions (key question):
71.4% of experts recommended the use of hemostatic clips and 28.6% recommended suturing (consensus achieved)
- Staple line reinforcement is necessary (key question):
71.4% experts agreed that staple line reinforcement is not necessary. Only 28.6% of experts recommended staple line reinforcement (consensus achieved)
- If the answer to the above statement is yes, then please state the preferred method for staple line reinforcement: 77.8% experts recommended oversewing as the method of choice if staple line reinforcement was being done (consensus achieved)
- Omentum must be routinely anchored to the staple line (key question):
81% experts disagreed that omentum must be routinely anchored to the staple line. Only 19% were in favour (consensus achieved)
- A leak test must be performed after the completion of LSG (key question):
71.4% of experts agreed on performing a leak test (consensus achieved)
- Intra-abdominal drain must be inserted after LSG (key question):
76.2% experts did not recommend the use of intra-abdominal drain after LSG. 19% considered it to be necessary (consensus achieved)
- 12 mm trocar sites must be routinely suture closed (key question):
85.7% experts agreed that trocar sites must be routinely sutured closed (consensus achieved)
- Oral contrast study is advisable on postoperative day 1 (key question):
61.9% experts did not recommend an oral contrast study on postoperative day 1 as compared to 38.1% who recommended it (consensus not achieved).
| Discussion|| |
This is an initiative of OSSI and is the first attempt toward a nationwide consensus on the step-by-step surgical technique of performing LSG. The Delphi technique has been recognized as a valid tool to reach a consensus between experts for a particular topic. The present expert group was representative of the LSG performing bariatric surgical community in India and was recommended by the executive committee of OSSI.
Sleeve gastrectomy remains one of the most popular procedures among Indian surgeons. With a nationwide registry in place and health insurance coming in, it is now imperative to standardize and streamline bariatric operations. Standardization is important to assure safety to protect patients, to promote interoperability and reproducibility, to promote common understanding about the procedure and to enable measurement and evaluation of performance.
In the past, there have been similar attempts to standardize LSG.,,,, However, when it comes to universal application, there can be challenges such as geographical heterogeneity, differences between healthcare systems in different countries, and diversity in views and practices of health-care practitioners. Patients in different countries also display biological, cultural, and social diversity.
In this study, out of 26 questions, 23 questions were identified as key questions.
Contrary to earlier studies and surveys, one of the practices that have come to fore in the last few years is regarding the preoperative need for a UGI endoscopy. With GERD being touted as one of the main complications after LSG and due to the concerns regarding developing Barrett's esophagus in the long term, there has been an increased emphasis on performing presurgery UGI endoscopy in patients planned for LSG. 75% of experts in our study recommended a preoperative UGI endoscopy for all patients undergoing LSG. A similar consensus was presented by Mahawar et al. in their study published in 2020 where 79.2% of the participants agreed on the need for a presurgery UGI endoscopy. This also explains the need for dissecting the left crus during LSG. 85.7% of experts in this study agreed that the left crus must be dissected properly during surgery to enable complete resection of the fundus, to identify the angle of His, and to rule out a hiatus hernia. When the group was asked about their choice of procedure in a case of medically refractory GERD with hiatus hernia-an overwhelming 100% response was – Roux en y gastric bypass. None of the experts recommended LSG for such a patient.
Although a consensus could not be reached about the technique of entering the abdomen, most experts (65%) preferred to enter the abdomen using a Veress needle as compared to 30% who used an optical trocar for entry. Ninety-five percent of the experts also agreed on the routine use of a liver retractor while performing LSG.
The use of GCT during LSG has been established before and an overwhelming 95.2% experts in this study recommended using a GCT during LSG. 76.2% experts preferred to insert the GCT before the first stapler fire. Since the inception of LSG, the size of GCT has been a point of discussion. If the size of the bougie used for calibration of the gastric sleeve is too small, it can impact the leak rates. On the other hand, higher diameters of GCT may lead to inadequate weight loss or faster weight regain in future. While back in 2013 most surgeons were using mixed GCT sizes between 32 and 50 Fr, in the present study, 95.2% of the experts agreed on a GCT size between 36 and 40 Fr. This is in accordance with one of the largest worldwide surveys done on perioperative practices of LSG in 863 surgeons. Forty percent of the surgeons in this survey reported using a 36 Fr GCT.
Antrum size or the distance of resection from the pylorus has been debated in the past. There have been two schools of thought with some surgeons preferring to resect the antrum and some preferring to preserve it. Antral length reported in the literature varies from 2 cm to 6–7 cm. It is suggested that antrum-preserving surgeries tend to improve gastric emptying, decrease intra-luminal pressure, prevent distal stenosis, and decrease the chances of proximal leak or reflux. On the other hand, antral resection tends to reduce gastric distensibility leading to early satiety and probably better weight loss. In a randomized study, Francesco Pitta et al. have reported that there is more acid reflux at 6 months in antral resecting sleeves, however, this difference is equalized at the end of 24 months. In this study, 85.7% of experts agreed that dissection must begin 3–5 cm proximal to the pylorus. This was similar to the perioperative practices survey of 863 surgeons where 72.65% reported antral resection between 3 and 5 cm.
Ninety-five percent experts in our study agreed that care must be taken not to narrow the sleeve at the level of the incisura. This was similar to the findings in the 2021 sleeve consensus by Mahawar et al. Narrowing at the incisura is one of the contributing mechanical factors for distal stenosis leading to increased intra-luminal pressure and subsequent proximal staple line leaks.
Not much evidence is available regarding the choice of linear stapler reloads in different parts of the stomach. Stomach tissue thickness varies from being the maximum in the antrum to being the thinnest in the fundus. Matching closed staple height to tissue thickness has been recommended while selecting the staple reloads. The choice of appropriate stapler can have an impact on leak rates as well as staple line bleeding., In this study, 73.7% agreed that a green (4.1 mm) or a purple tri-stapler (3–4 mm) cartridge must be used for the first fire in the antrum. While everyone agreed on using the purple tri-stapler for the second fire, the opinions were mixed when it came to choosing between green and blue (3.5 mm) cartridges and no consensus could be reached. For third and subsequent fires, 89.5% agreed that blue or purple cartridges can be used.
All experts agreed that the last stapler fire must be 0.5–1 cm away from the angle of His. This was similar to the 2021 consensus by Mahawar et al. Multiple studies in the past have also emphasized to stay at least 1 cm away from the gastro-esophageal junction to prevent leaks.
The literature is equivocal and contradictory when it comes to staple line reinforcement. There are studies that do not show any difference in leak rates after reinforcement whereas some show otherwise. However, there is some evidence that reinforcing the staple line leads to a decreased incidence of bleeding.,, In our study, 71.4% of experts agreed that hemostasis on the staple line can be achieved with hemostatic clips and 71.4% agreed that there is no need for staple line reinforcement. Eighty-one percent experts did not see any merit in routinely anchoring the omentum to the staple line.
71.4% of experts agreed on the routine use of an intra-operative leak test and 76.2% did not recommend the use of intra-abdominal drains.
Strengths and weaknesses
This consensus included 20 Indian bariatric surgeons with many years of experience in the field. Few of these experts have served as presidents of OSSI in the past. One of them has served as the president of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) as well as IFSO-APC. Many of them are office bearers in OSSI or have held a position in the past. In addition to years of experience, they also have multiple academic publications on the subject and can justifiably be considered experts in this field. This exercise must help to streamline the technique of LSG in India and can be used as a basis for future studies.
The cutoff of 70% for the consensus was arbitrary, however, 70% cut off has been used in multiple consensus studies done in the past. Hence, we decided to follow the same for this study. At the end of the day, consensus statements are considered to be opinions and more robust clinical studies are needed to confirm these findings. We do believe that until then, these can be used to guide practicing Indian surgeons as well as being the basis for future studies.
| Conclusion|| |
Bariatric surgery has come a long way in India since its inception in the late 90s and continues to evolve. In any specialty, it is important to introspect at regular intervals to consolidate and standardize existing surgical practices. As a conscientious society, OSSI has initiated multiple efforts toward this goal. This Delphi consensus is also a step towards improving the quality of surgical outcomes of LSG in India. This document has attempted to establish technical specifications of performing LSG which will in turn help to maximize the reliability and safety of the procedure. Until more robust studies come in, this consensus statement will help to provide a reference document which outlines the best way to perform LSG. This is a first step to provide a continually evolving foundation that enables the entire specialty to thrive better.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Luhar S, Timæus IM, Jones R, Cunningham S, Patel SA, Kinra S, et al
. Forecasting the prevalence of overweight and obesity in India to 2040. PLoS One 2020;15:e0229438.
Leotsakos A, Zheng H, Croteau R, Loeb JM, Sherman H, Hoffman C, et al
. Standardization in patient safety: The WHO high 5s project. Int J Qual Health Care 2014;26:109-16.
Welbourn R, Hollyman M, Kinsman R, Dixon J, Liem R, Ottosson J, et al.
Bariatric surgery worldwide: Baseline demographic description and one-year outcomes from the fourth IFSO global registry report 2018. Obes Surg 2019;29:782-95.
Bethlehem MS, Kramp KH, van Det MJ, ten Cate Hoedemaker HO, Veeger NJ, Pierie JP. Development of a standardized training course for laparoscopic procedures using Delphi methodology. J Surg Educ 2014;71:810-6.
Barrett D, Heale R. What are Delphi studies? Evid Based Nurs 2020;23:68-9.
Bhasker AG, Prasad A, Raj PP, Wadhawan R, Khaitan M, Agrawal AJ, et al.
Trends and progress of bariatric and metabolic surgery in India. Updates Surg 2020;72:743-9.
Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al
. International Sleeve Gastrectomy Expert Panel consensus statement: Best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 2012;8:8-19.
Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the fourth international consensus summit on sleeve gastrectomy. Obes Surg 2013;23:2013-7.
Kaijser MA, van Ramshorst GH, Emous M, Veeger NJ, van Wagensveld BA, Pierie JE. A Delphi consensus of the crucial steps in gastric bypass and sleeve gastrectomy procedures in the Netherlands. Obes Surg 2018;28:2634-43.
Adil MT, Aminian A, Bhasker AG, Rajan R, Corcelles R, Zerrweck C, et al
. Perioperative practices concerning sleeve gastrectomy – A survey of 863 surgeons with a cumulative experience of 520,230 procedures. Obes Surg 2020;30:483-92.
Mahawar KK, Omar I, Singhal R, Aggarwal S, Allouch MI, Alsabah SK, et al.
The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc 2021;35:7027-33.
Pavone G, Tartaglia N, Porfido A, Panzera P, Pacilli M, Ambrosi A. The new onset of GERD after sleeve gastrectomy: A systematic review. Ann Med Surg (Lond) 2022;77:103584.
Gaillard M, Lainas P, Agostini H, Dagher I, Tranchart H. Impact of the calibration bougie diametre during laparoscopic sleeve gastrectomy on the rate of postoperative staple-line leak (BOUST): Study protocol for a multicentre randomized prospective trial. Trials 2021;22:806.
Pizza F, D'Antonio D, Lucido FS, Gambardella C, Carbonell Asíns JA, Dell'Isola C, et al.
Correction to: Does antrum size matter in sleeve gastrectomy? A prospective randomized study. Surg Endosc 2021;35:3533.
Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: Review of its prevention and management. World J Gastroenterol 2014;20:13904-10.
Boeker C, Mall J, Reetz C, Yamac K, Wilkens L, Stroh C, et al
. Laparoscopic sleeve gastrectomy: Investigation of fundus wall thickness and staple height-an observational cohort study: Fundus wall thickness and leaks. Obes Surg 2017;27:3209-14.
Abu-Ghanem Y, Meydan C, Segev L, Rubin M, Blumenfeld O, Spivak H. Gastric wall thickness and the choice of linear staples in laparoscopic sleeve gastrectomy: Challenging conventional concepts. Obes Surg 2017;27:837-43.
Iossa A, Abdelgawad M, Watkins BM, Silecchia G. Leaks after laparoscopic sleeve gastrectomy: Overview of pathogenesis and risk factors. Langenbecks Arch Surg 2016;401:757-66.
Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: Prospective randomized clinical study comparing three different techniques. Obes Surg 2010;20:462-7.
Choi YY, Bae J, Hur KY, Choi D, Kim YJ. Reinforcing the staple line during laparoscopic sleeve gastrectomy: Does it have advantages? A meta-analysis. Obes Surg 2012;22:1206-13.
Gagner M, Buchwald JN. Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: A systematic review. Surg Obes Relat Dis 2014;10:713-23.