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Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review

Michel Gagner, M.D and Jane N. Buchwald, B.A.



The study compared laparoscopic sleeve gastrectomy (LSG) staple-line leak rates of 4 prevalent surgical options: no reinforcement, oversewing, nonabsorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM).


LSG is a multipurpose bariatric/metabolic procedure with effectiveness proven through the intermediate term. Staple-line leak is a severe complication of LSG for which no definitive method of prevention has been identified.


The systematic review study design was employed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement screening guidelines. Inclusion criteria centered on variables potentially relevant to LSG leak:

  • leak rate
  • age
  • gender
  • calibrating bougie size
  • distance between pylorus and gastric transection line
  • overall complication rate
  • mortality

Analysis of variance models were used to explore differences in select demographic and surgical technique variables characterizing each reinforcement group. An omnibus χ2 test followed by independent Fisher’s exact tests were used to compare leak rates.


There were 659 articles identified:

  • 41 duplicates were removed.
  • Of 618 remaining articles, 324 did not meet inclusion criteria.
  • Of the 294 remaining articles, 206 were eliminated (kin studies, those not reporting staple-line or leak incidence, those reporting discontinued products).

There were 88 papers included in the analysis. Statistically significant differences were found between groups across demographic and surgical variables studied (p<0.001).

  • There were 191 leaks in 8,920 patients; overall leak rate 2.1%.
  • Leak rates ranged from 1.09% (APM) to 3.3% (BPS) 
  • APM leak rate was significantly lower than other groups (p< 0.05).


Systematic review of 88 included studies representing 8,920 patients found that the leak rate in LSG was significantly lower using APM staple-line reinforcement than oversewing, BPS reinforcement, or no reinforcement.

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