Quality Improvement
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By surfacing, standardizing, and monitoring adherence to best practices, Theator can significantly improve the quality of surgical care while minimizing costs.

How does it work?

We identify areas for improvement in your health system and establish a baseline using current procedural volume, associated complication rates, and costs.

Through increased adoption of Theator's Surgical Intelligence Platform and adherence to proven surgical best practices, you will reduce the risk of unfavorable outcomes and their related costs.

Savings vary depending on average adherence levels.

Cost Savings in Sleeve Gastrectomy

Sleeve Gastrectomy Best Practices

The staple line should be reinforced by omental approximation.

Level I Evidence

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLICATIONS ✔️ Moderate reduction in the risk of postoperative bleeding* 🟢 [2/171 vs. 6/166, 30% lower incidence of bleeding in the reinforced group] ✔️ Moderate reduction in the risk of postoperative leaks* 🟢 [1/171 vs. 5/166, 33% fewer leaks in the reinforced group] HOSPITALIZATION ✔️ Reduced length of stay ⚪ [mean difference (MD) of -0.42 days] *Compared to no reinforcement of the staple line
Impact on operational efficiency	Increased operative time ⚪ [mean of +11.73 minutes]
Evidence-based research and references	Pilone V, Tramontano S, Renzulli M, Romano M, Monda A, Albanese A, Foletto M. Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study. BMC Surg. 2019 Nov 5;19(Suppl 1):56. doi: 10.1186/s12893-019-0507-7. PMID: 31690312; PMCID: PMC6829794. Afaneh C, Costa R, Pomp A, Dakin G. A prospective randomized controlled trial assessing the efficacy of omentopexy during laparoscopic sleeve gastrectomy in reducing postoperative gastrointestinal symptoms. Surg Endosc. 2015 Jan;29(1):41-7. doi: 10.1007/s00464-014-3651-2. Epub 2014 Jun 25. PMID: 24962864. Abosayed AK, Mostafa MS. Omentopexy Effect on the Upper Gastrointestinal Symptoms and the Esophagogastroduodenoscopy Findings in Patients Undergoing Sleeve Gastrectomy. Obes Surg. 2022 Jun;32(6):1864-1871. doi: 10.1007/s11695-022-05995-0. Epub 2022 Mar 23. PMID: 35320488; PMCID: PMC9072512. Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg. 2022 May;32(5):1466-1478. doi: 10.1007/s11695-022-05950-z. Epub 2022 Feb 16. PMID: 35169954; PMCID: PMC8986671.
Expert consensus	81.5% of experts agree: There is currently insufficient evidence to recommend the routine use of staple line buttressing. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	Difference in operative time was statistically significant. [3 studies; 343 patients (171 in the approximation group, 166 in the control group); MD 11.73; 95% confidence interval (CI) -7.86 to 31.33; heterogeneity (I2) = 95%, random-effect] Difference in hospital length of stay was statistically significant. [3 studies; 343 patients (171 in the approximation group, 166 in the control group); MD -0.42; 95% CI -0.96 to 0.14; I2 = 90%, random-effect] Difference in leak incidence rate was not statistically significant, however, 1 leak occurred in the reinforced group vs. 5 in the control group. [2 studies; 343 patients; relative risk (RR) = 0.30, 95% CI 0.05 to 5.44; I2 = 0%, random-effect] Difference in bleeding incidence rate was not statistically significant, however, 2 bleeds occurred in the reinforced group vs. 6 in the control group. [2 studies; 343 patients; RR = 0.30, 95% CI 0.09 to 1.65; I2 = 0%, random-effect]
Latest findings	[Aiolfi] Staple line reinforcement by suture oversewing (SR) was associated with significantly reduced risk of postoperative bleeding compared to no reinforcement (NR). [RR = 0.51; 95% credible interval (CrI) 0.31–0.88] No significant differences in postoperative bleeding risk were found for: SR vs. glue reinforcement (GR) [RR = 0.79; 95% CrI 0.44–1.47] SR vs. Gore® Seamguard® reinforcement (GoR) [RR = 0.82; 95% CrI 0.41–1.68] SR vs. clips reinforcement (CR) [RR = 0.84; 95% CrI 0.39–1.81] SR was associated with significantly reduced risk of leaks compared to NR. [RR = 0.56; 95% CrI 0.32–0.99] No significant differences in the risk of leaks were found for SR vs. GR [RR = 0.86; 95% CrI 0.45–1.62] SR was associated with increased operative time [17 studies, 3994 patients] compared to: NR [weighted mean difference (WMD) = 16.2; 95% CrI 10.8–21.7] GR [WMD = 15.0; 95% CrI 7.7–22.4] GoR [WMD = 15.5; 95% CrI 5.6–25.4]

Antrum preservation should be performed.

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLICATIONS ✔️ Reduced postoperative conversion 🔵 [1/107 vs. 0/112, 3.12 higher risk if the antrum is resected] ✔️ Reduced intraoperative adverse events 🔵 [4/127 vs. 2/128, 0.12 lower risk if the antrum is resected] ✔️ Reduced postoperative leaks 🟢 [8/349 vs. 4/356, 1.82 higher risk if the antrum is resected] ✔️ Reduced postoperative strictures 🔵 [2/172 vs. 2/174, 0.33 lower risk if the antrum is resected] ✔️ Reduced postoperative bleeding 🔵 [6/32 vs. 9/137, 0.66 lower risk if the antrum is resected] ✔️ Reduced postoperative mortality 🔵 [1/324 vs. 0/337, 3.14 higher risk if the antrum is resected] HOSPITALIZATION ✔️ Reduced length of stay ⚪ [longer by a mean of + 0.12 days if the antrum is resected] ✔️ Reduced 30-day reoperation ⚪ [2/127 vs. 2/128, 1.01 higher risk if the antrum is resected]
Impact on operational efficiency	Little-to-no impact on operative time [mean of + 0.51 minutes in if the antrum is resected]
Evidence-based research and references	Pizza F, D'Antonio D, Lucido FS, Gambardella C, Carbonell Asíns JA, Dell'Isola C, Tolone S. Does antrum size matter in sleeve gastrectomy? A prospective randomized study. Surg Endosc. 2021 Jul;35(7):3524-3532. doi: 10.1007/s00464-020-07811-1. Epub 2020 Aug 3. Erratum in: Surg Endosc. 2020 Aug 4;: PMID: 32691207. Eskandaros MS. Antrum Preservation Versus Antrum Resection in Laparoscopic Sleeve Gastrectomy With Effects on Gastric Emptying, Body Mass Index, and Type II Diabetes Remission in Diabetic Patients With Body Mass Index 30-40 kg/m2: a Randomized Controlled Study. Obes Surg. 2022 May;32(5):1412-1420. doi: 10.1007/s11695-022-05982-5. Epub 2022 Mar 19. PMID: 35304705; PMCID: PMC8986727. Omarov T, Samadov E, Coskun AK, Unlu A. Comparison of Weight Loss in Sleeve Gastrectomy Patients With and Without Antrectomy: a Prospective Randomized Study. Obes Surg. 2020 Feb;30(2):446-450. doi: 10.1007/s11695-019-04177-9. PMID: 31707570. Yu Q, Saeed K, Okida LF, Gutierrez Blanco DA, Lo Menzo E, Szomstein S, Rosenthal R. Outcomes of laparoscopic sleeve gastrectomy with and without antrectomy in severely obese subjects. Evidence from randomized controlled trials. Surg Obes Relat Dis. 2022 Mar;18(3):404-412. doi: 10.1016/j.soard.2021.11.016. Epub 2021 Nov 20. PMID: 34933811.
Expert consensus	85.2% of experts agree: Construction of the sleeve should start within 4–5 cm from the pylorus to avoid leaving behind a large antrum. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Latest findings	Difference in leak incidence was not statistically significant. [5 studies, 705 patients (349 vs. 356); odds ratio (OR) 1.82, 95% (confidence interval) CI 0.59 to 5.58; heterogeneity (I2) = 0%, random-effect] Difference in the incidence of bleeding was not statistically significant. [4 studies, 169 patients (132 vs. 137); OR 0.66, 95% CI 0.22 to 1.98; I2 = 0%, random-effect] Difference in the incidence of conversion was not statistically significant. [2 studies, 119 patients (107 vs. 112); OR 3.12, 95% CI 0.12 to 78.27; I2 = 0%, random-effect) Difference in the incidence of intraoperative adverse events was not statistically significant. [2 studies, 255 patients (127 vs. 128); OR 1.64, 95% CI 0.31 to 8.68; I2 = 0%, random-effect] Difference in the incidence of strictures was not statistically significant. [4 studies, 346 patients (172 vs. 174); OR 0.33, 95% CI 0.01 to 8.37; I2 = 0%, random-effect) Difference in the incidence of mortality was not statistically significant. [4 studies, 660 patients (327 vs. 333); OR 3.04, 95% CI 0.12 to 75.83; I2 = NA, random-effect) Difference in the incidence of reoperations within 30 days was not statistically significant. [2 studies, 255 patients (127 vs. 128); OR 1.01, 95% CI 0.14 to 7.28; I2 = 0%, random-effect) Difference in operative time was not statistically significant. [5 studies, 552 patients (278 vs. 274); mean difference (MD) 0.51; 95% CI -1.49 to 2.51; I2 = 0%, random-effect] Difference in hospital length of stay was statistically significant. [4 studies, 438 patients (213 vs. 215); MD 0.12; 95% CI -0.15 to 0.39; I2 = 62%, random-effect]

The staple line should be reinforced.

Level I Evidence

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLICATIONS ✘ No significant difference in postoperative leak rate 🟢 [1/1046 vs. 17/1017, 0.51 lower risk if the stapled line is reinforced] ✘ No significant difference in postoperative bleeding rate 🟢 [31/01046 vs. 76/1017, 0.20 lower risk if the stapled line is reinforced] HOSPITALIZATION ✔️ No significant difference in 30-day reoperation rates 🔵 [0/131 vs. 4/129, 0.33 lower risk if the stapled line is reinforced] ✔️ Reduced length of stay ⚪ [shorter by a mean of -0.12 days if the stapled line is reinforced]
Impact on operational efficiency	Potential increase in operative time depending on reinforcement technique ⚪ [mean of + 6.27 minutes]
Evidence-based research and references	Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg. 2022 May;32(5):1466-1478. doi: 10.1007/s11695-022-05950-z. Epub 2022 Feb 16. PMID: 35169954; PMCID: PMC8986671. Iannelli A, Chierici A, Castaldi A, Drai C, Schneck AS. Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy. Obes Surg. 2022 Aug;32(8):2605-2610. doi: 10.1007/s11695-022-06152-3. Epub 2022 Jun 13. PMID: 35696051. Guerrier JB, Mehaffey JH, Schirmer BD, Hallowell PT. Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg. 2018 May 1;84(5):690-694. PMID: 29966570. Hany M, Ibrahim M. Comparison Between Stable Line Reinforcement by Barbed Suture and Non-reinforcement in Sleeve Gastrectomy: a Randomized Prospective Controlled Study. Obes Surg. 2018 Aug;28(8):2157-2164. doi: 10.1007/s11695-018-3175-2. PMID: 29508273.
Expert consensus	81.5% of experts agree: There is currently insufficient evidence to recommend the routine use of staple line buttressing. 100% of experts agree: There is currently insufficient evidence to recommend the routine use of fibrin glue for the staple line. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	Difference in hospital length of stay was statistically significant. [8 studies, 1953 patients (995 vs. 968); mean difference (MD) -0.12; 95% confidence interval (CI) -0.28 to 0.05; heterogeneity (I2) = 74%, random-effect] Difference in operative time was statistically significant. [7 studies, 2003 patients (1016 vs. 987); MD 6.27; 95% CI -0.61 to 13.15; I2 = 99%, random-effect] Difference in leak incidence was not statistically significant [6 studies, 2063 patients (1046 vs. 1017); relative risk (RR) = 0.51, 95% CI 0.05 to 5.44; I2 = 0%, random-effect] Difference in the incidence of bleeding was not statistically significant. [7 studies, 2063 patients (1046 vs. 1017); RR = 0.20, 95% CI 0.01 to 4.14; I2 = 0%, random-effect] Difference in the incidence of reoperation was not statistically significant. [3 studies, 260 patients (131 vs. 129); RR = 0.33, 95% CI 0.01 to 7.87; I2 = 0%, random-effect] Some techniques may impact operative time, which was statistically different. [7 studies, 2003 patients; MD 2; 95% CI -2.28 to 5.28; I2 = 99%, random-effect]

The staple line should be oversewn.

Level I Evidence

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLICATIONS ✘ No significant difference in the risk of postoperative bleeding 🟢 [6/824 vs. 33/802, 0.20 lower risk if the staple line is reinforced] ✘ No significant difference in the risk of postoperative leaks 🟢 [0/824 vs. 14/802, 0.15 lower risk if the staple line is reinforced] HOSPITALIZATION ✔️ No significant difference in 30-day reoperation rates 🔵 [0/80 vs. 2/80, 0.33 lower risk if the staple line is not reinforced] ✔️ No impact on length of stay ⚪ [shorter by a mean of -0.04 days if the staple line is oversewn]
Impact on operational efficiency	Increased operative time 🟢 [mean of + 10.53 minutes if the staple line is oversewn]
Evidence-based research and references	Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg. 2022 May;32(5):1466-1478. doi: 10.1007/s11695-022-05950-z. Epub 2022 Feb 16. PMID: 35169954; PMCID: PMC8986671. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010 Apr;20(4):462-7. doi: 10.1007/s11695-009-0047-9. Epub 2009 Dec 11. PMID: 20012507. Guerrier JB, Mehaffey JH, Schirmer BD, Hallowell PT. Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg. 2018 May 1;84(5):690-694. PMID: 29966570. Di Capua F, Cesana GC, Uccelli M, Ciccarese F, Olmi S. Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study. J Laparoendosc Adv Surg Tech A. 2022 Nov;32(11):1176-1180. doi: 10.1089/lap.2022.0122. Epub 2022 Apr 25. PMID: 35467939.
Expert consensus	81.5% of experts agree: There is currently insufficient evidence to recommend routine use of staple line buttressing. 100% of experts agree: There is currently insufficient evidence to recommend the routine use of fibrin glue for the staple line. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	[Aiolfi] Staple line reinforcement by suture oversewing (SR) was associated with significantly reduced risk of postoperative bleeding compared to no reinforcement (NR). [relative risk (RR) = 0.51; 95% credible interval (CrI) 0.31–0.88] No significant differences in postoperative bleeding risk were found for: SR vs. glue reinforcement (GR) [RR = 0.79; 95% CrI 0.44–1.47] SR vs. Gore® Seamguard® reinforcement (GoR) [RR = 0.82; 95% CrI 0.41–1.68] SR vs. clips reinforcement (CR) [RR = 0.84; 95% CrI 0.39–1.81] SR was associated with significantly reduced risk of leaks compared to NR. [RR = 0.56; 95% CrI 0.32–0.99] No significant differences in the risk of leaks were found for SR vs. GR [RR = 0.86; 95% CrI 0.45–1.62] SR was associated with increased operative time [17 studies, 3994 patients] compared to: NR [weighted mean difference (WMD) = 16.2; 95% CrI 10.8–21.7] GR [WMD = 15.0; 95% CrI 7.7–22.4] GoR [WMD = 15.5; 95% CrI 5.6–25.4] [Dapri] 3 groups of 25 prospectively, randomly enrolled patients: Group 1: No staple line reinforcement Group 2: Buttressing the staple line with Gore® Seamguard® Group 3: Staple line suturing Mean total operative time was: Significantly shorter (p=0.02) for Group 1 than Group 2 [47.4 ± 10.7 min vs. 48.9 ± 18.4 min respectively] Significantly shorter (p=0.02) for Group 2 than Group 3 [48.9 ± 18.4 min vs. 59.9 ± 19.6 min respectively] Mean hospital stay (p=0.01) was: 3.6 ± 1.4 days for Group 1 (range 2–9) 3.9 ± 1.5 days for Group 2 (range 1–6) 2.8 ± 0.8 days for Group 3 (range 2–5) Postoperative leaks appeared in: 1 patient in Group 1 2 patients in Group 2 1 patient in Group 3

The staple line should be reinforced with absorbable polymer membrane.

Level VII Evidence

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLICATIONS ✘ No significant difference in the risk of postoperative bleeding 🟢 ✘ No significant difference in the risk of postoperative leaks 🟢 HOSPITALIZATION ✔️ No significant difference in 30-day reoperation rates 🔵 ✔️ Reduced length of stay ⚪
Impact on operational efficiency	Operative time ⚪
Evidence-based research and references	Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg. 2022 May;32(5):1466-1478. doi: 10.1007/s11695-022-05950-z. Epub 2022 Feb 16. PMID: 35169954; PMCID: PMC8986671. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010 Apr;20(4):462-7. doi: 10.1007/s11695-009-0047-9. Epub 2009 Dec 11. PMID: 20012507. Guerrier JB, Mehaffey JH, Schirmer BD, Hallowell PT. Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg. 2018 May 1;84(5):690-694. PMID: 29966570. Di Capua F, Cesana GC, Uccelli M, Ciccarese F, Olmi S. Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study. J Laparoendosc Adv Surg Tech A. 2022 Nov;32(11):1176-1180. doi: 10.1089/lap.2022.0122. Epub 2022 Apr 25. PMID: 35467939.
Expert consensus	81.5% of experts agree: There is currently insufficient evidence to recommend routine use of staple line buttressing. 100% of experts agree: There is currently insufficient evidence to recommend the routine use of fibrin glue for the staple line. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	[Aiolfi] Staple line reinforcement by suture oversewing (SR) was associated with significantly reduced risk of postoperative bleeding compared to no reinforcement (NR). [relative risk (RR) = 0.51; 95% credible interval (CrI) 0.31–0.88] No significant differences in postoperative bleeding risk were found for: SR vs. glue reinforcement (GR) [RR = 0.79; 95% CrI 0.44–1.47] SR vs. Gore® Seamguard® reinforcement (GoR) [RR = 0.82; 95% CrI 0.41–1.68] SR vs. clips reinforcement (CR) [RR = 0.84; 95% CrI 0.39–1.81] SR was associated with significantly reduced risk of leaks compared to NR. [RR = 0.56; 95% CrI 0.32–0.99] No significant differences in the risk of leaks were found for SR vs. GR [RR = 0.86; 95% CrI 0.45–1.62] SR was associated with increased operative time [17 studies, 3994 patients] compared to: NR [weighted mean difference (WMD) = 16.2; 95% CrI 10.8–21.7] GR [WMD = 15.0; 95% CrI 7.7–22.4] GoR [WMD = 15.5; 95% CrI 5.6–25.4] [Dapri] 3 groups of 25 prospectively, randomly enrolled patients: Group 1: No staple line reinforcement Group 2: Buttressing the staple line with Gore® Seamguard® Group 3: Staple line suturing Mean total operative time was: Significantly shorter (p=0.02) for Group 1 than Group 2 [47.4 ± 10.7 min vs. 48.9 ± 18.4 min respectively] Significantly shorter (p=0.02) for Group 2 than Group 3 [48.9 ± 18.4 min vs. 59.9 ± 19.6 min respectively] Mean hospital stay (p=0.01) was: 3.6 ± 1.4 days for Group 1 (range 2–9) 3.9 ± 1.5 days for Group 2 (range 1–6) 2.8 ± 0.8 days for Group 3 (range 2–5) Postoperative leaks appeared in: 1 patient in Group 1 2 patients in Group 2 1 patient in Group 3

Diaphragmatic defects should be closed during the sleeve procedure.

Level VII Evidence

Impact on clinical outcomes	QUALITY OF LIFE ✔️ Reduced GERD symptoms by 80% ✔️ Improved esophagitis by 88% ✔️ Reduced GERD-HRQL COMPLICATIONS & HOSPITALIZATION ✘ No proven differences based on available literature
Impact on operational efficiency	Potential increase in operative time if the hernia is repaired
Evidence-based research and references	Chen W, Feng J, Wang C, Wang Y, Yang W, Dong Z. Chinese Obesity and Metabolic Surgery Collaborative. Effect of Concomitant Laparoscopic Sleeve Gastrectomy and Hiatal Hernia Repair on Gastroesophageal Reflux Disease in Patients with Obesity: a Systematic Review and Meta-analysis. Obes Surg. 2021 Sep;31(9):3905-3918. doi: 10.1007/s11695-021-05545-0. Epub 2021 Jul 12. PMID: 34254259. Snyder B, Wilson E, Wilson T, Mehta S, Bajwa K, Klein C. A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair. Surg Obes Relat Dis. 2016 Nov;12(9):1681-1688. doi: 10.1016/j.soard.2016.09.004. Epub 2016 Sep 14. PMID: 27989522.
Expert consensus	92.6% of experts agree: Patients with preoperatively or intraoperatively diagnosed hiatal hernia (HH) should undergo a concomitant hiatal repair with sleeve gastrectomy. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	Morbidity was reported in 3 of the 5 observational studies available with no statistically significant differences. Differences were significant in: Reduction in GERD symptoms [odds ratio (OR) 0.20; 95% confidence interval (CI) 0.10 to 0.41; probability (P) < 0.00001] Improvement in esophagitis [OR 0.12; 95% CI 0.05 to 0.26; P < 0.001] Decrease in GERD-HRQL [mean difference (MD) 19.13; 95% CI −3.74 to 34.51; P = 0.01] The incidence of GERD remission was 68.0%. [95% CI 55.0 to 80.9%] The incidence of de novo GERD was 12%. [95% CI 8 to 16%] HH recurrence was 11%. [95% CI 4 to 19%] Sleeve gastrectomy and hiatal hernia repair is superior to sleeve gastrectomy alone in GERD remission. [OR 2.97; 95% CI 1.78 to 4.95; P < 0.0001]

A leak test should be performed.

Level VIII Evidence

Impact on clinical outcomes	COMPLICATIONS ✔️ Potential reduction in the risk of postoperative bleeding [propensity-matched analysis] ✘ No evidence of either benefit or harm from intraoperative leak test (IOLT) for preventing postoperative leaks [large retrospective observational study based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, 2019]
Impact on operational efficiency	Increased operative time [mean of +19.2 minutes, MBSAQIP registry analysis]
Evidence-based research and references	Yolsuriyanwong K, Ingviya T, Kongkamol C, Marcotte E, Chand B. Effects of intraoperative leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis of the MBSAQIP database. Surg Obes Relat Dis. 2019 Sep;15(9):1530-1540. doi: 10.1016/j.soard.2019.06.008. Epub 2019 Jun 17. PMID: 31474524. Jung JJ, Jackson T, Gordon L, Hutter MM. Intraoperative leak test is associated with a lower postoperative bleed rate in primary sleeve gastrectomy: a propensity-matched analysis of primary and revision bariatric surgery using the MBSAQIP database. Surg Endosc. 2022 Jan;36(1):753-763. doi: 10.1007/s00464-020-08264-2.
Additional information	No randomized controlled trials (RCTs) exist on this topic. Difference in operative time was statistically significant. [95% confidence interval (CI)] The overall level of evidence is low; however, from the analysis of the registry MBSAQIP database, it appears that > 80% of the included procedures involved the performance of a leak test, suggesting it is a common practice.

An orogastric tube (bougie) should be placed in the stomach to calibrate the pouch size.

Level I Evidence

	Quality of evidence: 🟢 High, 🔵 Moderate, ⚪ Low (see meta-analysis section at the bottom of this page for more info)
Impact on clinical outcomes	COMPLIACTIONS ✔️ Potential reduction in the risk of postoperative leaks* ⚪ [1/227 vs. 3/230, 0.51 lower risk if a bigger bougie is used] ✔️ Potential reduction in the risk of postoperative bleeding* ⚪ [4/165 vs. 3/156, 1.25 higher risk if a bigger bougie is used] ✔️ Potential reduction in the risk of postoperative strictures* ⚪ [0/30 vs. 2/30, 0.15 lower risk if a bigger bougie is used] HOSPITALIZATION ✔️ No impact on length of stay ⚪ [shorter by a mean of -0.14 days if a bigger bougie is used]
Impact on operational efficiency	Decreased operative time [mean of -48.09 minutes if a bigger bougie is used]
Evidence-based research and references	Omarov T, Samadov E, Coskun AK, Unlu A. Comparison of Weight Loss in Sleeve Gastrectomy Patients With and Without Antrectomy: a Prospective Randomized Study. Obes Surg. 2020 Feb;30(2):446-450. doi: 10.1007/s11695-019-04177-9. PMID: 31707570. Cal P, Deluca L, Jakob T, Fernández E. Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial. Surg Endosc. 2016 May;30(5):1812-5. doi: 10.1007/s00464-015-4450-0. Epub 2015 Jul 21. PMID: 26194265. Helmy, M. Ahmed. “Bougie size 32 versus 40 french in laparoscopic sleeve gastrectomy.” The Egyptian Journal of Surgery. 2018(37)200-208. Aldaqal SM, Al-Amoodi MS. Effect of Bougie Size and Level of Gastric Resection on Weight Loss Post Laparoscopic Sleeve Gastrectomy. J Obes Weight Loss Ther. 2013.
Expert consensus	92.5% of experts agree: The sleeve should be fashioned over an orogastric tube of 36–40 Fr. Mahawar KK, Omar I, Singhal R, et al. The first modified Delphi consensus statement on sleeve gastrectomy. Surg Endosc. 2021 Dec;35(12):7027-7033. doi: 10.1007/s00464-020-08216-w. Epub 2021 Jan 12. PMID: 33433676.
Additional information	The available evidence relates to the size of the bougie and, therefore, assesses the impact of bougie uses indirectly. The quality of evidence is low and biased by indirectness and inconsistency. Difference in operative time was statistically significant. [3 studies, 273 patients (141 vs. 132); mean difference (MD) -48.09; 95% confidence interval (CI) -143.30 to 47.13; heterogeneity (I2) = 100%, random-effect] Difference in hospital length of stay was not statistically significant. [4 studies, 321 patients (165 vs. 156); MD -0.14; 95% CI -0.93 to 0.65; I2 = 100%, random-effect] Difference in the incidence of leaks was not statistically significant. [5 studies, 457 patients (227 vs. 230); odds ratio (OR) 0.51, 95% CI 0.09 to 3.01; I2 = 0%, random-effect] Difference in the incidence of bleeding was not statistically significant. [4 studies, 321 patients (165 vs. 156); OR 1.25, 95% CI 0.30 to 5.25; I2 = 0%, random-effect]

Meta-analysis

GRADE quality of evidence scoring: The quality of the evidence is a judgment about the extent to which we can be confident that the estimates of effect are correct. These judgments are made using the GRADE system and are provided for each outcome. The judgments are based on the type of study design (randomized trials vs. observational studies), the risk of bias, the consistency of the results across studies, and the precision of the overall estimate across studies. For each outcome, the quality of the evidence is rated as high, moderate, low, or very low.

https://guides.library.stonybrook.edu/evidence-based-medicine/levels_of_evidence

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Sleeve Gastrectomy Best Practices

The staple line should be reinforced by omental approximation.

Antrum preservation should be performed.

The staple line should be reinforced.

The staple line should be oversewn.

The staple line should be reinforced with absorbable polymer membrane.

Diaphragmatic defects should be closed during the sleeve procedure.

A leak test should be performed.

An orogastric tube (bougie) should be placed in the stomach to calibrate the pouch size.

Meta-analysis

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