Benefits of staple line reinforcement, but more evidence needed

Suture oversewing (SR) during laparoscopic sleeve gastrectomy (LSG) seems to be associated with a reduced risk of postoperative bleeding, staple line leak and overall complications, compared to no reinforcement (NR), according to a team of international researchers. The outcomes, which reported in the paper, ‘Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials’, published in Obesity Surgery, also found that there were no significant differences in terms of sleeve stricture, surgical site infection (SSI), risk of reoperation and 30-day mortality among all treatments.

The researchers carried out a meta-analysis of randomised controlled trials (RCTs) to compare no reinforcement (NR) with differing staple line reinforcement techniques during LSG including suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore Seamguard, GoR) and clips reinforcement (CR).

After performing a literature review, a total, of 3,994 patients were included the study, of which:

  • 1,641 (41.1%) underwent NR

  • 1,507 (37.7%) SR

  • 689 (17.2%) GR

  • 107 (2.7%) GoR; and

  • 50 (1.3%) CR

The researchers reported that SR was associated with a significantly reduced postoperative bleeding compared to NR, while no significant differences were found for SR vs. GR, SR vs. GoR, and SR vs. CR. The global heterogeneity was low (I2=8.2%; 95% CrI 0.0–23.7%). In addition, SR was associated with a significantly reduced risk of staple line leak vs NR, whilst no significant differences were found between SR vs. GR, SR vs. GoR and SR vs. CR. The global heterogeneity was zero (I2=0.0%; 95% CrI 0.0–23.3%).


Unsurprisingly, all staple line reinforcement techniques were associated with significantly longer operative times vs NR, apart from CR. Regarding sleeve stenosis, no significant differences were found for SR vs. NR, SR vs. GR and SR vs. CR. Instances of SSI were similar for SR vs. NR, SR vs. GR and SR vs. GoR.


For postoperative complications, SR was associated with a significantly reduced risk vs NR and no significant differences were found for SR vs. GR, SR vs. GoR and SR vs. CR. The authors noted that hospital length of stay and 30-day mortality were comparable among treatments.


Crucially, the authors noted that surgeons’ performance with different levels of training and experience could have impacted on patient outcomes and can be a significant source of bias, as it has been previously demonstrated that operator-related factors are of outmost importance for determining operative time, blood loss, and overall complications.


“Data regarding GoR and CR are still limited; therefore, further trials reporting outcomes for these surgical techniques are necessary,” the authors concluded. “As the overall quality of included RCTs was narrow because of issues regarding blinding, methods of randomization, and operating surgeon proficiency, further well-designed appropriate powered trials are warranted to corroborate our findings.”


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