Diagnostic Value of Erythrocyte Sedimentation Rate Levels as a Predictor of Staple-Line Leakage in Bariatric Surgery

Introduction

Bariatric surgery has become one of the most effective treatments for morbid obesity, with extremely good long-term results on weight loss, comorbidities, and low mortality as well as postoperative complications rate. ¹ Bariatric surgery of morbid obese has been improved in the past 15 years. ² According to the every published report, bariatric surgery is one of the safest operations with complications of <1%.^3,4 However, the knowledge about its anatomic reconstruction, the physiological effects of bariatric surgery, and even the prevention and management of complications after bariatric procedure have not directly incorporated in general procedure preparing programs.^5,6 Hence, general surgeons should expand their knowledge in basic anatomic, clinical, and surgical understanding because they might face postoperatively acute or chronic complications for their patients. ⁶ Bariatric surgery can cause early complications, including primarily staple-line leakage and bleeding in the immediate postoperative days. Late postoperative complications include abscess development or delayed postoperative staple-line leakage with fistula as well as sleeve stenosis. In addition, some patients can develop a rare case of sleeve gastrectomy, which is deep vein thrombosis. ⁷

As mentioned, gastrointestinal staple-line leakage remains one of the most unavoidable complications after procedure, resulting in increased health care cost and postoperative pain in patients. ⁸ According to several meta-analyses reports, gastrointestinal leak rate has been estimated ranging from 2.5% to 7% after various types of bariatric surgery.^6–9 However, the postoperative gastrointestinal leak has been constantly dropping recently and its occurrence is low ¹⁰ ; nonetheless, the leakage is still a principal complication, leading to increased morbidity and mortality rate. Various surgeons have employed different interventions for detecting leaks either intraoperatively or postoperatively such as placement of an orogastric tube with distention of the gastric pouch with air, endoscopy with carbon dioxide insufflations, and methylene blue dye. ⁶

Researchers have recently found that in patients with low body mass index (BMI), postoperative increased heart rate (tachycardia >120 beats per minute [bpm]), evidence of respiratory distress and decreased hemoglobin were significantly associated with bleeding.^11,12 Fazl Alizadeh et al. reported that oxygen dependency, hypoalbuminemia, sleep apnea, hypertension, and diabetes were critical factors related to increased risk of leak. ¹³ In addition, preoperative platelet count and Preoperative Normalised Ratio and systolic blood pressure were not significantly related to postoperative bleeding. ¹² On the other side, the association between preoperative partial thromboplastin time and bleeding was significant. ¹² Burgos et al. believed that increased white blood cell (WBC) and C-reactive protein (CRP) levels, abdominal pain, tachycardia, tachypnea, and fever are more common in subjects with gastric leak. ¹¹

From clinical perspective, an erythrocyte sedimentation rate (ESR) is one of the blood tests, is usually ordered by physicians for patients with symptoms such as inflammation in the body, headaches, fever, joint stiffness, neck or shoulder pain, weight loss, loss of appetite, anemia, and fever.^14,15

Higher ESR levels may be associated with a medical condition, such as infection or inflammation (especially inflammatory bowel disease), rheumatoid arthritis, cardiovascular or kidney disease, and some types of cancers. Higher ESR levels do not necessarily mean that the patients have a medical condition that requires treatment. ¹⁵ For example, certain medications and dietary supplements can also affect ESR results, including oral contraceptives, cortisone, vitamin A, and aspirin. A moderate ESR may indicate pregnancy, menstruation, or anemia, rather than an inflammatory disease. A slow ESR may indicate a blood disorder such as polycythemia, sickle cell anemia, and leukocytosis.^14,15

The main purpose of this study was to evaluate correlations of ESR, CRP, and platelet count with incidence of intermediate gastrointestinal leak in obese subjects who underwent sleeve gastrectomy.

Materials and Methods

Results

We investigated that among the 2350 patients who underwent sleeve gastrectomy from 2016 to 2019, 50 subjects experienced gastric leak (2.12%). The total sample size was 199 patients, including 50 cases experiencing leak and 149 controls (randomized from 2350 patients). 69.8% of the cohort, 70% of cases, and 69.8% of controls were females. Mean age for the cohort was 38.15 (minimum 12 years old and maximum 63 years old). ESR mean was 73.1 mm/h for cases, which is statistically significant in patients with leakage compared with the control group. Also, ESR serum level mean was 31.34 mm/h for control groups. More descriptive results are reported in Table 1.

Results of adjusted and unadjusted logistic regression are reported in Table 2. Females were taken as reference group due to bigger proportion in the sample. The only independent variable that had significant association with staple-line leakage was ESR (OR = 1.051). This means by every 1 U increase of ESR, the odds for staple-line leakage occurrence increase by 5.1%.

Discussion

Sleeve gastrectomy procedure has been popularly employed for the management of morbid obesity, and this operation has a series of inevitable complications. Staple-line leakage is one of these complications, ranging from 7% to 25% after bariatric surgery. ⁶ Although researchers mentioned various approaches, surgeons utilize the endoscopic approach such as stent inserting, clips, and biologic glue. ¹⁶ This study comprises our experiences with 199 patients, with or without staple-line leakage, after sleeve gastrectomy. The final adjusted prediction model of log (odds) for leaking outcome can be used to predict leaking outcome. Exponential of (y) gives odds of occurrence of leaking for each patient with archived ESR. It should be noted that because of the impact of other factors affecting on staple-line leakage outcome, this model might not be 100% precise.

According to the results, ESR serum level in patients with leak after sleeve gastrectomy was significantly increased in comparison with ESR levels of patients without any complications after the surgery. ESR serum levels mean were 73.1 mm/h for cases and 31.34 mm/h for controls.

As previously mentioned, high ESR serum levels can be seen in various conditions such as cardiovascular and kidney disease and obstructive sleep apnea.^14,15 However, after bariatric surgery, patients with obesity start to develop weight loss that may lead to an increase in ESR serum levels, but ESR mean in patients with leak compared with control group was significantly higher, which means, by every 1 unit increase in ESR serum levels, the odds for leakage occurrence increase by 5.1% in patients after bariatric surgery. The normal range of ESR for men is 0–22 mm/h and 0–29 mm/h for women, ¹⁵ but in subjects with obesity due to a series of interactions, it can get elevated. This means macrophage and adipose tissue secrete cytokines and interleukins, resulted in stimulation of liver to produce fibrinogen, CRP and haptoglobin, which in turn elevate ESR serum levels during inflammation (Fig. 1). ¹⁵ Therefore, with this diagnostic value of ESR, surgeons can employ ESR serum levels immediately after procedure, instead of common interventions that might increase the cost and duration of treatment. ⁶ In vulnerable patients with abnormal ESR levels, a series of technical recommendations can be done to prevent leakage after operation: use a 40 Fr size or more bougie, initiate the gastric transection 5–6 cm from the pylorus, use proper cartridge colors from antrum to fundus, reinforce the staple line with buttress material, ⁵ order an appropriate staple line, ⁶ perform an intraoperative methylene blue test, remove the crotch staples, maintain suitable traction on the stomach before firing as well as avert from the angle of His (at least 1 cm) and check the staple-line bleeding during the procedure.

OPEN IN VIEWER

FIG. 1.

The impacts of inflammation on serum level of ESR. ESR, erythrocyte sedimentation rate.

Although gastric leakage can be caused by either mechanical or ischemic reasons, ESR serum levels might be a reliable predictor for postoperative leakage. Hence, in patients with higher ESR, more sedulous management (leaving a shorter antrum and using a smaller bougie) can be performed by surgeons and this may open a new chapter in terms of personalized surgery with lesser cases of leak complications among subjects. Previous studies have not paid sufficient attention to the molecular dimension of gastric leak, instead most of the studies focused on mechanical dimension and the management of this complication. Researchers found that the greater bougie was related to a leakage rate of 0.6% in comparison with those who used smaller sizes whose leak rate was 2.8%. ¹⁶ However, Keren et al. reported normal ESR levels of patients with gastric leakage, which is in contrast to our findings. ¹⁷

Other variables, including gender, age as well as platelet count and CRP serum level, were not significantly different compared with control patients. In line with these results, Keren et al., in 2014, and Surace et al., in 2011, reported that gastric leak after sleeve gastrectomy present no correlation with serum levels of CRP and WBC.^17,18 Nevertheless, more studies are warranted to address the question why ESR serum level has been increased without any significant changes in CRP levels.

Conclusion

This study reports the clinical correlation of gastric leakage and platelet count, ESR and CRP serum levels, and gives practical instructions to prevent and manage leaks after sleeve gastrectomy. In short, these recommendations are as follows: (1) use greater size of bougie, (2) begin the gastric transection 5–6 cm from the pylorus, (3) use suitable cartridge colors, (4) reinforce the staple line with buttress material, (5) follow an appropriate staple line, (6) remove the crotch staples, (7) maintain adequate traction on the stomach before firing, (8) keep distance from the angle of His, (9) check the staple-line bleeding, and (10) perform a methylene blue test during the procedure.