FYI - a new survey study on leaks. Not surprisingly, smaller sleeves are associated with greater risk of leaks.

http://www.ncbi.nlm.nih.gov/pubmed/22179470 

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INTRODUCTION: Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation.

METHODS:

An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.

RESULTS:  The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI... (see article for rest)

 For some reason OH is truncating the results section which I copied from pubmed. There must be some invisible character in the text I'm copying that OH doesn't like. You will need to click on the link to see the results. 

One of the important sentences in the results: " The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%."

Just an FYI, this makes perfect sense.  Inexperienced surgeons are now doing VSG's for the first time and telling their patients that it is OK that they know how to do surgery in general and the VSG is just a very simple surgery.  My surgeon's leak rate is under .05% and he uses 32 f boughie.  That is why Frisco always tells everybody that boughie size should not be negotiable with your doctor.  If you doctor is not comfortable doing a smaller stomach, either take what he is offering and live with it or go someplace else.  By the way, the leak rate is just one concern, there are many others associated with where the cut is placed on the stomach that can lead to increased reflux, nausea and food getting stock.  There is a lot more to this surgery then just cutting a straight line.

Ditto this!

 I disagree with Frisco as far as negotiating bougie size upwards. I think it should be well within a patient's rights to ask for a larger than normal stomach. I think I wouldn't push a surgeon to make a smaller size than he or she recommends, however.

Personally, I will not be going to the LapSF doctors because I distrust the emphasis on small stomachs. I don't believe the evidence is there to support it, and small sleeves are associated with more problems of a wide variety. I also suspect that the smaller stomachs are going to be associated with a higher risk of cancer some day. There's just no where for the acid to go.

I don't think Frisco means negotiating up, I don't think he would have even thought of that.  He just means negotiating down is a bad idea. 

KEWL...HUGE POLL...VERY SIMILAR results from ASMBS polling in 2009 even tho much fewer pts!

Yes it is WELL KNOWN 32F BOUGIES are notorious for HIGHER LEAK RATE!! see below Despite LAPSF/Dr. Cirangle's highly STANDARDIZED - ONE SIZE FITS ALL 32F bougie usage...and his EXPERIENCE, THROWING EVERYTHING but the KITCHEN SINK at that STAPLE LINE because he does NOT believe in OR leak tests ...he STILL CAUSES LEAKS!! last one a month or two ago. IT HAPPENS to the BEST of em!

I would encourage VSGrs RESEARCH bougie sizes, techniques of their docs...and discuss PRIOR TO VSG!!

...I WAS ABLE TO NEGOTIATE MY BOUGIE after RESEARCHING surgically induced GERD! 3 yrs ago!

From my BOUGIES in VSG blog...
LapSF/Dr. Criangle on their routine use of 32F bougies in VSG "Optimal weight loss may require the smallest possible pouch, which may yield the highest leak rate" .

Here's yer article!!


Surg Endosc. 2011 Dec 17. [Epub ahead of print]

Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.

Aurora AR, Khaitan L, Saber AA.

Source

Department of Surgery, University Hospitals Case Medical Center, Lakeside 7, 11100 Euclid Avenue, Cleveland, Ohio, 44106, USA, [email protected].

Abstract

INTRODUCTION:

Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation.

METHODS:

An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.

RESULTS:

The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) 50 kg/m(2)] and 2.2% for BMI Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of the cases. Most leaks were diagnosed after discharge . Endoscopic management is a viable options for leaks and was documented in 11% of cases as successful.

CONCLUSIONS: Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4% Attention to detail specifically at the esophagogastric juncture cannot be stressed enough. Careful patient selelction (BMI 50kg/m(2) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will
happen after patient discharge.

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I HAD TO TYPE IT OUT...hopefully got it! Too many ARROWS in the study so it cut off EVERYTHING ELSE I TYPED AFTER TOO!! oh well a bit of what I posted!

...THE REASON LEAKS ARE FOUND AFTER DISCHARGE...is because SWELLIJNG /INFLAMMATION PLUG EM UP, SEAL EM!! THAT LEAK GOT THERE from CUTTING!!
Once that swelling goes down....Houston we got a problem!! but that LEAK WAS ALREADY THERE!!

oh...also in REVISIONs from lapband to VSG...LEAK RATE JUMPS to a little over 6% due to EROSION, SCAR TISSUE....this study doesn't address IF there is an overall INCREASE in that stat .

In VIRGIN VSG it WAS 2.2 % reported by ASMBS in 2009 I beleive!

THANKS FOR POSTING THIS AVONLEA...I love this stuff!! KEEP UP THE GREAT WORK...

I was doomed from the beginning!..Bigger sleeve, leak, and now, badass GERD!!!....

PS..Would I do it all over again?...Hell, Yes!!!

Hugs

Donna

Thanx for posting that. Also buried in the text of that article is another fascinating one on non-surgical approachs to repair leaks. Here is that link: http://www.ncbi.nlm.nih.gov/pubmed/19381737