Suture reinforcement versus no reinforcement in laparoscopic sleeve gastrectomy: what do randomized trials show? A meta-analysis and trial sequential analysis.
Brucchi Francesco F, Sassun Richard R, Sperotto Beatrice B, Cirocchi Roberto R et al.
Suture reinforcement (SR) of the staple line is widely used in laparoscopic sleeve gastrectomy (LSG), but whether it prevents staple-line leak remains unresolved. We updated the randomized evidence comparing SR with no reinforcement (NR) and assessed its robustness for leak. PubMed, MEDLINE, Embase, and CENTRAL were searched to 31 July 2026, with hand-searching of previous meta-analyses. Risk of bias was assessed for each outcome (RoB 2). Rare events were pooled with Peto odds ratios and Mantel-Haenszel risk ratios (RRs), and operative time as a mean difference (MD). Trial sequential analysis (TSA) and GRADE were applied. Fourteen RCTs (2,646 patients; SR 1,410, NR 1,236) are included; seven are at high risk of bias. SR probably reduces postoperative bleeding (RR 0.36, 95% CI 0.21-0.62; 25 fewer per 1,000; moderate certainty), consistently across risk-of-bias subgroups. Leak occurs in 0.9% with SR and 2.3% with NR (RR 0.38, 95% CI 0.20-0.72), but the reduction is driven by small trials at high risk of bias and is not significant when these are excluded (RR 0.48, 95% CI 0.22-1.08). TSA shows that 21.4% of the required information has accrued, without crossing the monitoring boundary; certainty is very low. SR may increase operative time (MD + 18.5 min, 95% CI 13.3-23.7; low certainty). Suture reinforcement probably reduces postoperative bleeding at the cost of a longer operation. Its effect on staple-line leak is very uncertain and rests on small trials at high risk of bias; adequately powered contemporary trials are needed.