Strategy against accidental stapling of NGT during Sleeve Gastrectomy

Clinical Case

The increased number of bariatric procedures will be associated with an increase in the number of complications. Stapling of the nasogastric tube during sleeve gastrectomy is an unusual and dreaded complication in bariatric surgery. There are intraoperative signs that can alert the surgeon to the adverse events related to the nasogastric tube, such as:

• Stapler failure  
• Tissue deformity in the staple jaws 
• Need to use excessive force to close / shoot the stapler 
• Excessive bleeding at the staple line 
• Inability to remove the nasogastric tube at the end of the stapling or anastomosis 

When this happens the recommendations are: 

1.- Intraoperative endoscopy is an excellent tool for the surgeon which can also be considered and used. If you have an endoscope ASK FOR IT. 

2.- Check the staple line 

3.- Perform a cold dissection with scissors releasing the probe from the gastric tissue and make sure that you have released everything, examining the probe in its entirety. Remove the tube and tissue involved. 

4.- At this point you have 3 options:

• In most cases (approximately 85%) this complication occurs in the second and third shots due the height of the stapling. You can perform a Roux-en-Y gastric bypass (RYGB)  conversion.
 
• Recalibrate with a bougie and try to restaple. If you are going to do this we recommend being careful with the incisura angularis and we suggest that you give a traction stitch to each end of the defect before stapling to avoid future stenosis.
• Manual suture of the defect associated with epipoplasty.

5.- Remove and open the specimen. 

6.-  Intraoperative tests, including gastric inflation with dye (e.g., methylene blue) or air (bubble test) can test the strength of the staple line after the repair.

 7.- Local drainage is recommended for these complications. However, the best treatment for this complication is prevention. Prevention strategies should include constant communication with the anesthesiologist and removal or manipulation of an NGT prior to stapling or suturing.