Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Abstract

Purpose Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR. Materials and Methods Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures. Results Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality. Conclusions SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted. Graphical abstract

Staple line reinforcement for intracorporeal anastomosis reduces time for reconstruction during laparoscopic gastrectomy for gastric cancer Running Τitle: Staple line reinforcement for gastric cancer

“…In a meta-analysis of randomized controlled trials for bariatric surgery, such as laparoscopic sleeve gastrectomy, suture oversewing seemed to be associated with a reduced risk of postoperative bleeding, staple line leak, and overall complications; however, no differences were found compared with bioabsorbable materials in the staple line [4]. The procedure for sleeve gastrectomy involves a mostly vertical stapled transection of the stomach and removal of the gastric fundus to create a tubular alimentary channel along the lesser curvature; reconstruction was not included.…”

“…In the present study, no signi cant differences were observed in postoperative complications, including postoperative bleeding and anastomotic leakage. Previous studies have demonstrated that staple line treatment techniques, such as oversewing or SLR via roo ng or buttressing, have been implemented to mitigate the risk of staple line complications [4,13,14]. Ojima et al reported that no anastomosis-related complications such as anastomotic leakage, anastomotic stricture, and postoperative gastrointestinal bleeding were found in 24 consecutive patients with gastric cancer who underwent a reinforced stapling technique for reconstruction after laparoscopic distal gastrectomy [15].…”

“…Various staple line reinforcement (SLR) techniques have been developed for clinical use to reduce the occurrence of incisional leakage [3,4]. Different techniques for SLR have been reported, which include oversewing the staple line, brin glue application, use of bioabsorbable buttressing material, and omental or jejunal wrapping [5].…”

Standardoperationen in der Adipositaschirurgie

“…Das Risiko der Nachblutung aus der Klammernahtreihe kann durch eine kurzfristige medikamentöse Blutdruckerhöhung (130 – 150 mmHg) vor Beendigung der Operation und gezielte Blutstillung (Titanclips, Naht, Gewebekleber, biodegradable Klammernahtbezüge) signifikant reduziert werden. Auch wenn hierdurch Adhäsionen induziert werden können, gibt es keine Hinweise auf erhöhtes Risiko von Sleeve-Stenosen 14 .…”

Role of Staple Line Reinforcement by Oversewing in Preventing Leakage and Bleeding after Sleeve Gastrectomy

“…Higher incidence of bleeding and leakage occurred at the start of the learning curve of most surgeons, so we think that correct surgical technique with soft handling of tissues plays a great role in decreasing the incidence of complications. Several studies have revealed that SLR reduces the risk of bleeding and leakage, but its efficacy is still controversial [10].…”