“Inverted corner” for sleeve gastrectomy

• DOI: 10.1016/j.soard.2012.01.007
• Publication Date: 2012-01-17T08:18:57Z
• Authors: Milton Owens; John Sczepaniak; Arash Mahdavi
• Keywords: 03 medical and health sciences; Postoperative Complications; 0302 clinical medicine; Gastrectomy; Medical Illustration; Weight Loss; Gastroesophageal Reflux; Humans; Anastomotic Leak; 3. Good health

Sleeve gastrectomy is an appealing weight loss operation. Patients lose approximately 60% of their excess weight in 1 year [1], and weight regain, which is a complication of all rocedures, is amenable to a variety of different surgical pproaches [2,3]. Moreover, long-term complications, such as bowel obstruction, iron deficiency, and marginal ulcer after gastric bypass or erosion or slippage after adjustable gastric banding, seem unlikely or impossible. Leakage after sleeve gastrectomy occurs in approximately 2% of cases [4,5] and is difficult to treat [6,7]. Heartburn, affecting 25–40% of patients after surgery, is a lesser, but clearly troublesome, side effect of sleeve surgery [7]. We have developed a modification to the usual surgical technique that we believe minimizes both leaks and heartburn. Approximately 3 of 4 leaks developing after sleeve gastrectomy occur near the gastroesophageal junction [7,8]. The suggested causes include the relative thinness of the stomach wall near the esophagus [9] and the potential for distal obstruction, particularly near the “crow’s foot” [8]. It has been suggested that the gastric transection and staple line should be completed a short distance lateral to the gastroesophageal junction to reduce the occurrence of a leak (Fig. 1) [8,10]. However, this means increasing the sleeve diameter in that area and, according to La Place’s law, the tension on the wall is also increased and, by implication, the likelihood of a blowout and leakage is also increased. We have managed this problem by inverting the corner and sleeve for a length of 2 or 3 in., thereby doubling the thickness of the closure and narrowing the sleeve relative to its more distal diameter (Fig. 2). Because some of the blood supply to the stomach at the left gastroesophageal junction