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Comment on: Stapleless laparoscopic sleeve gastrectomy. Preliminary report.
Author’s Accepted Manuscript Comment on: Stapleless laparoscopic sleeve gastrectomy. Preliminary report Richard M. Peterson
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30037-0 http://dx.doi.org/10.1016/j.soard.2017.01.023 SOARD2902
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Richard M. Peterson, Comment on: Stapleless laparoscopic sleeve gastrectomy. Preliminary report, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.01.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comment on: Stapleless Laparoscopic Sleeve Gastrectomy. Preliminary report.
Richard M Peterson, MD MPH FACS FASMBS Department of General and Minimally Invasive Surgery University of Texas Health Science Center San Antonio San Antonio, TX
Corresponding Author: Name: Richard Peterson Address: 7703 Floyd Curl Dr., Mail Code 7842, San Antonio, TX 78229-3900 Telephone number: 210-567-5730 Fax number: 210-567-5797 E-mail: [email protected]
Short Title: Comment on: Stapleless Laparoscopic Sleeve Gastrectomy. Preliminary report.
I would first start off with commending the authors for bringing forth a continuation of a technique to assist individuals suffering from obesity and lacking optimum treatment secondary to cost or availability of technology. The overall concept of this technique is a good one, especially in areas where the gold standard of stapler technology is not available.
One of the most challenging aspects of the technique described by the authors is that it will be limited to a select group of surgeons that have this skill set available. As highlighted in their own paper, the learning curve is expected to be steeper. Many surgeons are not comfortable with advanced laparoscopic suturing. The technique itself in the paper is well described and based on the description I believe the reader would be able to reproduce the operation.
It is not a surprise that the LigaSure AtlasTM (LSA) (Valleylab, Tyco, Boulder, CO, USA) technology had failure on the stomach at the antrum given the thickness of this tissue. It is an off-label application for this device. Overcoming the opening of the stomach and suturing as the technique progressed is a reasonable approach to limiting contamination and spillage.
There is still a cost associated with the device utilized in the described technique and I wonder if that would remain an issue in locations that have restrictions on overall cost of equipment. This is especially true when compared to electrocautery and suture alone or even simplifying to scissors and suture alone. Neither of these two techniques provides as optimal hemostasis as the LSA or staples, but costs may be further reduced. Faced with a similar situation in an austere operating environment on a previous deployment where we were tasked with removing a gastrointestinal stromal tumor (GIST) from a local
dignitary laparoscopically – we were challenged with performing a partial gastrectomy without the option of staples and there was no LSA available. Use of electrocautery was feasible to resect the portion of stomach along the greater curvature and closure of the stomach in two layers laparoscopically was achieved.
Another area of concern I have with the final aspect of the technique is that no leak test was performed. While the authors contend that there may be controversy surrounding routinely performing an intraoperative leak test and the methods that are used to perform them, I would argue that with a technique that is as highly technically demanding as the one described it may offer a further level of safety for early detection of a technical failure.
This is a good proof of concept piece. I believe the next steps should be 2-fold. First would be to increase the sample size of this group and follow for complications. Secondly the results should be matched with the stapled technique to determine if the postoperative complications remain comparable to what is considered the standard of care worldwide. Understanding that the staple technology may be out of reach in some areas secondary to cost, it is imperative that we determine that this technique does not result in higher complication rates. Having said that, often the standard of care argument is best applied locally/regionally and circumstances may dictate this for specific regions.
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30037-0 http://dx.doi.org/10.1016/j.soard.2017.01.023 SOARD2902
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Richard M. Peterson, Comment on: Stapleless laparoscopic sleeve gastrectomy. Preliminary report, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.01.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comment on: Stapleless Laparoscopic Sleeve Gastrectomy. Preliminary report.
Richard M Peterson, MD MPH FACS FASMBS Department of General and Minimally Invasive Surgery University of Texas Health Science Center San Antonio San Antonio, TX
Corresponding Author: Name: Richard Peterson Address: 7703 Floyd Curl Dr., Mail Code 7842, San Antonio, TX 78229-3900 Telephone number: 210-567-5730 Fax number: 210-567-5797 E-mail: [email protected]
Short Title: Comment on: Stapleless Laparoscopic Sleeve Gastrectomy. Preliminary report.
I would first start off with commending the authors for bringing forth a continuation of a technique to assist individuals suffering from obesity and lacking optimum treatment secondary to cost or availability of technology. The overall concept of this technique is a good one, especially in areas where the gold standard of stapler technology is not available.
One of the most challenging aspects of the technique described by the authors is that it will be limited to a select group of surgeons that have this skill set available. As highlighted in their own paper, the learning curve is expected to be steeper. Many surgeons are not comfortable with advanced laparoscopic suturing. The technique itself in the paper is well described and based on the description I believe the reader would be able to reproduce the operation.
It is not a surprise that the LigaSure AtlasTM (LSA) (Valleylab, Tyco, Boulder, CO, USA) technology had failure on the stomach at the antrum given the thickness of this tissue. It is an off-label application for this device. Overcoming the opening of the stomach and suturing as the technique progressed is a reasonable approach to limiting contamination and spillage.
There is still a cost associated with the device utilized in the described technique and I wonder if that would remain an issue in locations that have restrictions on overall cost of equipment. This is especially true when compared to electrocautery and suture alone or even simplifying to scissors and suture alone. Neither of these two techniques provides as optimal hemostasis as the LSA or staples, but costs may be further reduced. Faced with a similar situation in an austere operating environment on a previous deployment where we were tasked with removing a gastrointestinal stromal tumor (GIST) from a local
dignitary laparoscopically – we were challenged with performing a partial gastrectomy without the option of staples and there was no LSA available. Use of electrocautery was feasible to resect the portion of stomach along the greater curvature and closure of the stomach in two layers laparoscopically was achieved.
Another area of concern I have with the final aspect of the technique is that no leak test was performed. While the authors contend that there may be controversy surrounding routinely performing an intraoperative leak test and the methods that are used to perform them, I would argue that with a technique that is as highly technically demanding as the one described it may offer a further level of safety for early detection of a technical failure.
This is a good proof of concept piece. I believe the next steps should be 2-fold. First would be to increase the sample size of this group and follow for complications. Secondly the results should be matched with the stapled technique to determine if the postoperative complications remain comparable to what is considered the standard of care worldwide. Understanding that the staple technology may be out of reach in some areas secondary to cost, it is imperative that we determine that this technique does not result in higher complication rates. Having said that, often the standard of care argument is best applied locally/regionally and circumstances may dictate this for specific regions.