Surgical Strategies That May Decrease Leak After Laparoscopic Sleeve Gastrectomy A Systematic Review and Meta-Analysis of 9991 Cases

Objective: To conduct a systematic review to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG). Background: LSG is growing in popularity as a primary bariatric procedure. Technical aspects of LSG including bougie size remain controversial. Methods: Our systematic review yielded 112 studies encompassing 9991 LSG patients. A general estimating equation (GEE) model was used to calculate the odds ratio (OR) for leak based on bougie size, distance from the pylorus, and use of buttressing on the staple line. Baseline characteristics, including age and body mass index (BMI), were included. A linear repeated measures regression model compared excess weight loss (%EWL) between bougie sizes. Results: A total of 198 leaks in 8922 patients (2.2%) were identified. The GEE model revealed that the risk of leak decreased with bougie >= 40 Fr (OR = 0.53, 95% CI = [0.37-0.77]; P = 0.0009). Buttressing did not impact leak. There was no difference in %EWL between bougie <40 Fr and bougie >= 40 Fr up to 36 months (mean: 70.1% EWL; P = 0.273). Distance from the pylorus did not affect leak or %EWL. Conclusions: Utilizing bougie >= 40 Fr may decrease leak without impacting %EWL up to 3 years. Distance from the pylorus does not impact leak or weight loss. Buttressing does not seem to impact leak; however, if surgeons desire to buttress, bioabsorbable material is the most common type used. Longer-term studies are needed to definitively determine the effect of bougie size on weight loss after LSG.