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Mesenteric defect closures

Sutures more effective than clips for mesenteric defect closures

The mesenteric defects were closed with non-absorbable, running sutures in 6,149 patients (17.7%), with non-absorbable metal clips in 19,436 patients (56.0%) and left open in 9,122 patients (26.3%)

Closure of the mesenteric defects using either non-absorbable metal clips or non-absorbable running sutures is a safe and effective measure to reduce the risk for small bowel obstruction after laparoscopic gastric bypass surgery, according to researchers from the Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. However, they noted that sutures appear slightly more effective and should remain gold standard for mesenteric defects closure.

The study, ‘Comparing Techniques for Mesenteric Defects Closure in Laparoscopic Gastric Bypass Surgery—a Register-Based Cohort Study’, published in Obesity Surgery, compared closure of the mesenteric defects in laparoscopic gastric bypass surgery with sutures, metal clips or non-closure, based on the hypothesis that there is no difference between sutures and clips, and that the risk for small bowel obstruction is reduced with both methods compared to non-closure.

It is well-documented that the closure of the mesenteric defects reduces the risk for small bowel obstruction and is now an accepted part of any laparoscopic gastric bypass procedure in many parts of the world. Nevertheless, there are several methods are available for mesenteric defects closure. (eg. non-absorbable sutures and metal clips), but to date, no large trial comparing these two methods has been conducted.

Using data from the Scandinavian Obesity Surgery Registry (SOReg), the main outcome measures were serious postoperative complication within 30 days after surgery, and reoperation for small bowel obstruction within five years after surgery. Quality-of-life before and after surgery, duration of surgery, and risk factors for complication were also analysed.

Outcomes

In total, 38,078 patients operated with a primary laparoscopic gastric bypass procedure during the inclusion period were identified. After exclusion of retrocolic procedures (n=184), mixed or non-reported mesenteric defects closure techniques (n=2,294), closure of only one mesenteric defect (n=803) and conversion to open surgery (n=90) - 34,707 patients remained for analysis.

Completed quality-of-life forms were collected both at baseline and year-year follow-up from 9,219 patients concerning the OP-scale and 9,190 patients concerning SF-36RAND. Follow-up at day 30 was 98.1% (n=34,040). The mesenteric defects were closed with non-absorbable, running sutures in 6,149 patients (17.7%), with non-absorbable metal clips in 19,436 patients (56.0%) and left open in 9,122 patients (26.3%). The mean age at the time of surgery was 40.8± 1.24 years and mean BMI 42.1±5.27, the majority were women (n=26,284; 75.7%), and 19,067 (54.9%) had a comorbid disease.

The mean operation time was 70.3±24.53min in the sutures group, 60.6±20.02 min (p<0.0001) in the clips group, and 79.9±36.26 min (p<0.0001) in the non-closure group. A postoperative complication occurred within 30 days after 2,632 (7.7%) operations, with 1,044 (3.1%) meeting the criteria for serious postoperative complication. A serious postoperative complication occurred in 174 (2.9%) patients with sutures, 592 (3.1%; adjusted OR 1.18, 95% CI 0.98–1.42, p=0.079) with clips, and 278 (3.1%; adjusted OR 1.05, 95% CI 0.85–1.29, p = 0.658) in the non-closure group.

A total of 2,243 patients underwent reoperation for small bowel obstruction (Figure 1). In the sutures group, 341 patients were operated for small bowel obstruction within five years after surgery (cumulative incidence 6.9%), while 956 were operated for small bowel obstruction in the clips group (cumulative incidence 7.3%, unadjusted HR 1.13, 95% CI 0.99–1.28, p=0.060; adjusted HR 1.16, 95% CI 1.02–1.32, p=0.0.026) and 946 in the non-closure group (cumulative incidence 11.2%, unadjusted HR 1.63, 95% CI 1.44–1.84, p<0.0001; adjusted HR 1.74 95% CI 1.53–1.98, p<0.0001).

Figure 1: Cumulative probability of operation for small bowel obstruction

Other significant risk factors were female sex (adjusted HR 1.20, 95% CI 1.07–1.34, p=0.001), while increasing age (adjusted HR 0.98, 95% CI 0.98–0.99/year, p < 0.0001), increased BMI (adjusted HR 0.97, 95%CI 0.96–0.98/BMI-unit, p<0.0001), hypertension (adjusted HR 0.80, 95% CI 0.71–0.91, p=0.001), and diabetes (adjusted HR 0.70, 95% CI 0.60–0.83, p<0.0001) were associated with reduced risk.

In the sutures group, 598 patients underwent an abdominal operation within five years (cumulative incidence 12.0%), while 1,720 were operated in the clips group (cumulative incidence 12.6%, p=0.008), and 1,489 in the non-closure group (cumulative incidence 17.4%, p<0.0001).

The OP-score prior to surgery was 62.3±25.40 in the sutures group, 61.5 ± 26.35 in the clips group (p=0.270), and 60.7±26.74 (p=0.026) in the non-closure group. Two years after surgery, the OP-score was 18.2±22.63 in the sutures group, 20.6±24.27 (p<0.0001) in the clips group and 21.7±24.55 (p<0.0001) in the non-closure group.

The mean improvement in OP-score was lower for clips (mean difference 2.63, 95% CI 1.46–3.81, p<0.0001; adjusted mean difference 2.32, 95% CI 1.16–3.49, p<0.0001) and non-closure (mean difference 1.97, 95% CI 1.36–2.58, p<0.0001, adjusted mean difference 1.54, 95% CI 0.93–2.14, p<0.0001) compared to sutures.

Bodily pain on the SF-36 RAND prior to surgery was 55.8± 6.94 in the sutures group, 54.5±27.11 (p=0.065) in the clips group and 56.2 ± 27.06 (p=0.599) in the non-closure group. Two years after surgery, bodily pain was 75.5±28.62 in the sutures group, 72.3±29.37 (p<0.0001) in the clips group and 72.3±29.09 (p=0.0001) in the non-closure group. The mean improvement in bodily pain was lower for clips (mean difference 2.54, 95% CI 1.17–3.91, p=0.0003, adjusted mean difference 1.94, 95% CI 0.56–3.31, p=0.006) and non-closure (mean difference 1.64, 95% CI 0.93–2.36, p<0.0001; adjusted mean difference 1.21, 95% CI 0.49–1.92, p=0.001) compared to sutures.

“Closure of the mesenteric defects using either sutures or clips in antecolic laparoscopic gastric bypass surgery was associated with lower risk for small bowel obstruction compared to non-closure,” the authors noted. “However, sutures were slightly more effective after adjustment for other potential risk factors. Both groups improved health-related quality-of-life and bodily pain significantly, but slightly less so with clips compared to sutures…Although the differences in health-related quality-of-life were negligible from a clinical perspective, all things considered, sutures appear slightly more effective than clips.”

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