Patients undergoing laparoscopic sleeve gastrectomy (LSG) using the latest Titan SGS single-fire stapler (developed by Standard Bariatrics, acquired by Teleflex in September 2022) have a shorter length of hospital stay, fewer readmissions, reduced post-operative nausea/vomiting events and operative times, according to researchers from Grand Rapids/Michigan State University, Grand Rapids, MI.
The Titan SGS stapler is a powered, 23cm single-fire stapler that employs staples of varying height (1.2 to 2.2mm) to produce a straight and reproducible gastric sleeve in one fire. According the company, the Titan Stapler provides equal, uninterrupted compression along the entirety of the staple line, and fires staples from proximal to distal. As a result, the alignment of the stapling is ensured at the most critical portion of the staple line where leaks typically occur. The Titan stapler’s proposed benefits include reduced operative time, reduced staple loads, removal of staple load junction sites, and eliminating potential angulation between staple loads. It is also proposed that a single-fire staple line will reduce unwanted twisting and narrowing at the incisura.
This retrospective study included 807 patients who underwent LSG using the Titan Stapler and were compared to 3,829 patients who underwent LSG using a sequential staple firing technique. Cases done using the first-generation stapler, which is no longer on the market, were excluded.
The researchers sought to assess patient outcomes with the stapler, and further demonstrate that it is a safe, effective tool and improves efficiency in performing laparoscopic sleeve gastrectomy.
A similar operative technique and instruments were used for all patients. All procedures were performed either laparoscopic or robotic assisted. All sequential firing LSGs were performed using the Echelon 60-mm powered stapler (Ethicon Biosurgery) over a 38–40 French bougie (ViSiGi 3D, Boehringer Labs). All staple loads were fired with buttressing material in place (SEAMGUARD, WL Gore & Associates) or Peri-Strips® (Baxter Healthcare). In all cases, the proximal 5–10 cm of the staple line was oversewn with 2–0 Vicryl (Ethicon Biosurgery) or Stratafix (Ethicon Biosurgery) securing omentum to the staple line. Topical haemostatic agents were used on a case-by-case basis at the discretion of the surgeon.
For LSG using the Titan stapler, once the greater curve dissection was completed, the stapler was introduced via a 19mm trocar placed to the right of the umbilicus approximately 27cm inferior to the xiphoid process. The stapler was fired over a 38Fr ballooned bougie (Teleflex) filled with 14cc of saline, from 5-6cm proximal to the pylorus along the greater curve ending at the Angle of His. The staple line is then similarly managed with over-sewing and topical haemostatic agent application. The 19mm port site was closed in all cases to prevent an incisional hernia.
Outcomes
For the Titan stapler arm, the median patient age was 42 years (IQR 33–52) as compared with 44 years (IQR 35–54) for the sequential staple fire arm. The difference was statistically significant (p < 0.01). A total of 629 patients were female (77.9%) and 178 were male. The median initial BMI was 47.1 in the Titan arm compared to 47.6 (in the sequential staple fire arm.
The authors reported that the median operative duration for sequential staple firing LSG was 55mins and 47mins for the Titan, it was 47 min (p< 0.01). The median length of stay was 1 day for sequential staple firing and 1 day for Titan, although the narrower IQR for the Titan arm implied a significant difference (p<0.01) between patient groups along with increased consistency.
Titan patients experienced fewer 30-day readmissions, especially those related to nausea/vomiting. The proportions of reoperations and leaks by 30-days were favourable to the Titan arm but did not reach statistical significance. Post-operative bleeds within 72hrs were similar between the two cohorts. Sequential staple fire patients had 1–2% improved weight loss at six months following surgery (Table 1). No post-operative port site hernias or instrument misfires and malfunctions have been encountered to date.
“The simplified and efficient stapling process offered by this instrument has the potential to enhance the safety and effectiveness of LSG, ultimately benefiting patients and healthcare providers,” the authors concluded. “We have provided evidence that the device is safe and effective and may result in improved outcomes regarding length of stay, readmission, reoperation, and stricture formation. In addition, we have documented considerable time savings with this technique. Further studies will be done to determine its ability to reduce post-operative reflux which we have noticed anecdotally but have not investigated further.”
The outcomes were featured in the paper, ‘Perioperative Outcomes Using Single-Fire Stapler’, published in Obesity Surgery. To access this paper, please click here
Comentários