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SLEEVE BLEED

Haemorrhagic complications post-LSG calculated by SLEEVE BLEED

Risk assessment model can contribute to surgical decision-making process

Researchers from the Military Institute of Medicine, Warsaw, Poland, who developed a predictive model for haemorrhagic complications after laparoscopic sleeve gastrectomy (LSG), have reported an association between haemorrhagic complications and obstructive sleep apnoea, hypertension, level of expertise in bariatric surgery and reinforcement of the staple line. They said that this risk assessment model can contribute to surgical decision-making process.

The researchers note that although LSG is one of the most frequently performed bariatric procedures, however it is associated with a risk of serious surgical complications including gastric fistulas and haemorrhagic complications. Despite this, most researchers focus on gastric leakage and neglect haemorrhagic complications. The study, ‘Prediction Model for Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy: Development of SLEEVE BLEED Calculator’, was published in the journal Obesity Surgery.

"The association between hypertension, obstructive sleep apnoea, and postoperative haemorrhagic complications should be investigated in further studies.”

To develop a predictive model, 552 patients who received a LSG as a primary bariatric procedure, from January 2013 to February 2015, were retrospectively collected from medical records. The primary outcome was surgical revision due to haemorrhagic complications, which included bleeding and the presence of large haematomas on ultrasound examination. Bleeding was diagnosed on the basis of vital signs, including tachycardia (>120 beats per minute), hypotension (<90/60 mmHg), and clinical exam, including abdominal pain and drainage type.

In such cases, the researchers initiated fluid resuscitation and performed laboratory tests, as well as ultrasound examination. Those patients with a poor response to fluid resuscitation, the presence of free fluid or hematoma in the peritoneal cavity on ultrasound examination, were returned to the operating room for diagnostic laparoscopy.

The independent demographic variables were sex, age, and BMI. Comorbidities included diabetes, hypertension, obstructive sleep apnoea, dyslipidaemia, hypothyroidism and hyperthyroidism. Several surgical factors were also considered including:

  • the surgeon’s level of expertise (>50 laparoscopic bariatric surgeries per year)
  • the surgeon’s qualifications (senior vs. resident), and;
  • staple line reinforcement (running suture vs. none).

Outcomes

The researchers report that the reoperation rate due to haemorrhagic complications was 4.02%, with the majority of the bleeding complications occurred at the staple line (12 cases). They were unable to locate the source of the bleeding in six cases, with bleeding arose from the omentum in only three cases.

Of the 12 examined variables, four were associated with a risk of haemorrhagic complications. Protective factors for haemorrhagic complications were no history of obstructive sleep apnoea (odds ratio [OR], 0.22; 95 % confidence interval [CI], 0.05–0.94) and no history of hypertension (OR, 0.38; 95 % CI, 0.14–1.05). Two factors were associated with a higher risk of HC: a low level of surgical expertise (OR, 2.85; 95 % CI, 1.08–7.53) and no staple line reinforcement (OR, 3.34; 95 % CI, 1.21–9.21).

The examples of the estimated probability of HC are as follows:

  • Estimated risk of HC in a healthy patient who was operated on by an experienced surgeon and the staple line was reinforced by running suture would be 2.19%
  • Estimated risk of HC in a healthy patient who was operated on by a less experienced surgeon and the staple line was reinforced by running suture would be 3.63%
  • Estimated risk of HC in a healthy patient who was operated on by an experienced surgeon and without staple line reinforcement would be 4.25%
  • Estimated risk of HC in a patient with hypertension who was operated on by an experienced surgeon and without staple line reinforcement would be 6.72%
  • Estimated risk of HC in a healthy patient who was operated on by a less experienced surgeon and without staple line reinforcement would be 6.98%
  • Estimated risk of HC in a patient with hypertension who was operated by a less experienced surgeon and without staple line reinforcement would be 10.81%
  • Estimated risk of HC in a patient with hypertension and obstructive sleep apnea who was operated by a less experienced surgeon and without staple line reinforcement would be 20.42%

The researcher note that the data show that the surgeon’s level of expertise in bariatric surgery is essential, in contrast to the surgeon’s qualifications, which were not associated with the risk of haemorrhagic complications.

“It is debatable whether or not cases of bleeding from different sites should be included in an analysis because certain factors predispose patients to certain types of bleeding. For example, reinforcement of the staple line with suture may reduce bleeding from the staple line,” they conclude. “…Our risk assessment model for haemorrhagic complications after LSG can contribute to surgical decision-making process. The association between hypertension, obstructive sleep apnoea, and postoperative haemorrhagic complications should be investigated in further studies.”

A free version of the haemorrhagic complications risk calculator called SLEEVE BLEED is available here under the bariatric surgery section.

The article was edited from the original article, under the Creative Commons license

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