Hybrid partial ALPPS. a feasible approach in case of right trisegmentectomy and macrovascular invasion

I read with great interest the excellent article ‘‘The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies’’1 from Berger et al, published in the September 2016 issue of Annals of Surgery. The role of the impact of different technical details on the outcome of sleeve gastrectomies is particularly relevant, and several aspects pointed out by the authors certainly deserve the maximum attention of the international bariatric surgical community. The set of data reported in the study is impressive and very informative. However, some concerns need to be raised because they constitute excellent examples of the strength and limitations of a data registry observational retrospective study, even if large and very well conducted. One of the main conclusion of the article is related to the increased risk of a leak associated with buttressing. Certainly, the authors clarify that the literature on staple line reinforcement has conflicting results. They also acknowledge the lack of specific information about the buttressing products used in their series. This limitation is, indeed, very relevant as it has been shown that there are significant differences between them.