American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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Esophagus, Stomach, and Duodenum Part II

Selected Readings in General Surgery Cover ImageVol. 44, No. 6

  • Benign Esophageal Tumors
  • Motility Abnormalities
  • Esophageal Cancer
  • Peptic Ulcer Disease
  • Zollinger-Ellison Syndrome
  • Giant Gastric Ulcer
  • Gastric Polyps
  • Surgery for Obesity
  • Gastroparesis
  • Gastric Cancer

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Rebibo L, Dhahri A, Chati R, Cosse C, Huet E, Regimbeau JM. Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial. Ann Surg. 2018.

Commentary by: Raul Rosenthal, MD, FACS

The authors are to be commended for trying to investigate how to decrease the incidence of complications and improve the outcomes of a surgical approach that is already considered amongst the safest in the surgical literature. Despite its perceived simplicity, sleeve gastrectomy (SG) is a complex surgical procedure that can result in some of the most difficult to manage and serious complications, such as a chronic proximal staple line disruption (SLD), in addition to bleeding or obstruction.

In a prospective randomized controlled trial of 586 severely obese subjects that underwent SG, the authors came to the conclusion that adding a fibrin sealant (FS) to the staple line does not prevent complications when compared to patients that underwent the same procedure without the use of an FS.

Surgeons should take into consideration that when performing SG, this is the longest staple line in gastrointestinal surgery. As such, mechanical errors may occur that can ultimately result in obstruction, gastroesophageal reflux disease (GERD), bleeding, or SLD. The cause of SLD after SG is multifactorial and is most likely the result of a technical error in judgment by the surgeon in charge.

In order to avoid anastomotic dehiscence or SLD when conducting gastrointestinal surgery, the concept of elevated intraluminal pressure (ILP) and distal obstruction (DO) have to be kept in mind. Yoshua et al. demonstrated that when performing an SG, the ILP in the stomach will rise from 32 to 48 mm Hg. Adding DO at the level of the incisura or creating a too-narrow tube will further raise the already elevated ILP. Utilizing too small of a bougie or applying too much pressure on it at the level of the incisura angularis, excessive lateral traction, or rolling of the anterior and posterior walls of the stomach by the assistant surgeon when stapling will result in stenosis or corkscrew anatomy. The latter errors will result in DO and elevated ILP that will, in turn, generate and perpetuate a proximal SLD. The use of a FS to resolve the above-mentioned errors is futile.

Secondly, another important technical pitfall to keep in mind when stapling during gastrointestinal surgery is tissue thickness (TT). The distal part on the lesser curvature of the stomach is the region where we will find the thickest wall in the GI tract. Utilizing a shallow stapler can result in a weak tissue approximation, bleeding, and subsequent SLD. Here again, utilizing a FS will not help prevent a staple line complication. I tell my residents and fellows that when they see intraluminal bleeding after an anastomotic or stapling procedure, they should expect leaking as well. The bleeding episode is a sentinel event that announces the leak that is soon to come.

Finally, the third factor that can contribute to generate an SLD is a vascular one—the challenge of preventing bleeding versus creating ischemia. The stomach is one of the organs that has the best blood supply in the GI tract. We say that, after a total gastrectomy, “the pathologist is calling us from the lab because the stomach is still bleeding.” Generating an SLD due to ischemia of the stomach wall with the left and right gastric arteries being intact is highly unlikely. Stapling and TT are again to be considered when trying to avoid bleeding. We find the thinnest part of the gastric wall on the opposite site of the gastric outlet and at the level of the GE junction. Utilizing too tall of a stapler in this area will result in bleeding, hematoma, and possible SLD. While FS could help diminish capillary bleeding when applied to a raw surface, (i.e., liver resection), its use to prevent bleeding and SLD from poor tissue apposition is not realistic.

One could have predicted that the result of this study would not shed new light on the prevention and management of SLD during SG. Nevertheless, the authors should be praised for their efforts in conducting this study. Bariatric surgeons should be reminded that while it is perceived as a “simple” procedure, SG is not an “easy” approach.

Recommended Reading

Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

Ahmad SA, Xia BT, Bailey CE, et al. An update on gastric cancer. Curr Probl Surg. 2016 Oct;53(10):449-90.

    Ahmad and colleagues offer a comprehensive description of gastric adenocarcinoma, including histological classification systems, etiology/pathophysiology definitions, and advancements in treatment options.

Ha C, Regan J, Cetindag IB, Ali A, Mellinger JD. Benign esophageal tumors. Surg Clin North Am. 2015;95(3):491-514.

    Ha and colleagues describe benign esophageal and paraesophageal masses and cysts as well as associated symptoms and categorization techniques and recommendations.

Klevebro F, Ekman S, Nilsson M. Current trends in multimodality treatment of esophageal and gastroesophageal junction cancer - Review article. Surg Oncol. 2017;26(3):290-295.

    Klevebro and colleagues review the scientific evidence for the different curatively intended treatment strategies that are available today; additionally, it describes other relevant studies and trials.

Laine L. CLINICAL PRACTICE. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer. N Engl J Med. 2016;374(24):2367-2376.

    Laine reviews nonvariceal upper gastrointestinal bleeding.

Makris EA, Poultsides GA. Surgical Considerations in the Management of Gastric Adenocarcinoma. Surg Clin North Am. 2017;97(2):295-316.

    Makris and Poultsides describe, analyze, and compare the primary surgical treatment options for gastric adenocarcinoma, including complete surgical resection, Billroth I or Billroth II reconstructions, and Roux-en-Y anastomosis.

Mendelson AH, Donowitz M. Catching the Zebra: Clinical Pearls and Pitfalls for the Successful Diagnosis of Zollinger-Ellison Syndrome. Dig Dis Sci. 2017;62(9):2258-2265.

    Mendelson and Donowitz present an overview of ZES that focuses on clinical presentation and available biochemical and imaging testing modalities.

Ryan CE, Paniccia A, Meguid RA, McCarter MD. Transthoracic Anastomotic Leak After Esophagectomy: Current Trends. Ann Surg Oncol. 2017;24(1):281-290.

    Ryan and colleagues analyze morbidity and mortality differences based on anastomosis leak locations.

Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes—5-Year Outcomes. N Engl J Med. 2017;376(7):641-651. Free Full Text

    Schauer and colleagues assess three-year outcomes of uncontrolled diabetes patients randomized to receive either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.

Schmocker RK, Lidor AO. Management of Non-neoplastic Gastric Lesions. Surg Clin North Am. 2017;97(2):387-403.

    Schmocker and Lidor review diagnostic and management considerations for benign gastric lesions.

Thiels CA, Ikoma N, Fournier K, et al. Repeat staging laparoscopy for gastric cancer after preoperative therapy. J Surg Oncol. 2018;118(1):61-67.

    Thiels and colleagues perform a retrospective analysis of patients with gastric adenocarcinoma and identify factors associated with positive exploration.