POSTOPERATIVE BLEEDING AFTER LAPAROSCOPIC GASTRIC-SLEEVE: WHAT OPTIONS DO WE HAVE?
Laparoscopic sleeve gastrectomy is a relatively simple procedure, but the complications can quickly become life-threating. The aim of this study was to investigate based on our experience when is best to follow a conservative protocol in postoperative bleeding after sleeve gastrectomy. The study is retrospective, we identified a number of 150 cases of sleeve gastrectomy, of which 18 has postoperative bleeding. A conservative approach with close observation (ultrasound, CT, Hb levels) was practiced in 10 cases and no surgical intervention was required. The recommendations are as follows: The first and obvious recommendation is to stop anticoagulants. The perigastric drainage should drain, if Hb levels go down an nothing is coming through the drain consider other sources of bleed or try to reopen the blocked drain. A blood cloth developed around the bleeder may maintain the active bleed due to local fibrinolysis, in these cases, one should take into consideration guided drainage (ultrasound/CT) and monitor Hb levels afterward. The presence of a small perigastric collection without clinical manifestation should be left as such. Take into consideration reintervention if: signs of hypovolemia are present (tachycardia, hypotension, profuse sweating), Hb below 7g/dL. The patient's clinical state should always play an important role in decision making.
 Chen B, Kiriakopoulos A, Tsakayannis D, Wachtel MS, Linos D, Frezza EE. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg. 2009;19: 166 –172.
 Giannopoulos GA, Tzanakis NE, Rallis GE, Efstathiou SP, Tsigris C, Nikiteas NI. Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis. Surg Endosc. 2010;24: 2782–2788.
 Knapps J, Ghanem M, Clements J, Merchant AM. A systematic review of staple-line reinforcement in laparoscopic sleeve gastrectomy. JSLS. 2013;17: 390 –399.
 Frezza EE, Reddy S, Gee LL, et al. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. 2009;19(6):1672–7.
 Gill RS, Whitlock KA, Mohamed R, Sarkhoush K, Birch DW, Karmali S. The role of upper endoscopy in treating postoperative complications in bariatric surgery. J Interv Gastroenterol. 2012;2(1): 37–41.
 Gagner M, Deitel M, Erickson AL, Crosby RD (2013) Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg 23(12):2013–2017.
 De Berardis G, Lucisano G, D’Ettorre A, et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA. 2012;307: 2286–94.
 R. A. Klaassen, C. A. Selles, J. W. van den Berg, M. M. Poelman and E. van der Harst. Tranexamic acid therapy for postoperative bleeding after bariatric surgery. BMC Obesity (2018) 5:36 https://doi.org/10.1186/s40608-018-0213-5.
 Timm RW, Asher RM, Tellio KR, Welling AL, Clymer JW, Amaral JF. Sealing vessels up to 7 mm in diameter solely with ultrasonic technology. Med Devices (Auckl). 2014;7: 263–271. Published 2014 Jul 30. doi:10.2147/MDER.S66848
 Huang R, Gagner MA. Thickness calibration device is needed to determine staple height and avoid leaks in laparoscopic sleeve gastrectomy. Obes Surg. 2015;25: 2360–7.
 Rogula T, Khorgami Z, Bazan M, Mamolea C, Acquafresca P, El-Shazly O, Aminian A, Schauer P (2015) Comparison of reinforcement techniques using suture on staple-line in sleeve gastrectomy. Obes Surg 25(11):2219–2224
 Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009;102: 297–306.
 De Angelis F, Abdelgawad M, Rizzello M, Mattia C, Silecchia G Surg Endosc. 2017 Sep; 31(9):3547-3551.
 Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic bariatric surgery. Ann Gastroenterol. 2018;31(1):56–64. doi:10.20524/aog.2017.0201.