title: Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review.
abstract: OBJECTIVE
  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).
  
  
  BACKGROUND
  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.
  
  
  METHODS
  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, and mortality. Analysis of variance models were used to explore differences in select demographic and surgical technique variables characterizing each reinforcement group. An omnibus χ(2) test followed by independent Fisher's exact tests were used to compare leak rates.
  
  
  RESULTS
  There were 659 articles identified; 41 duplicates 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Hopital du Sacré Coeur, Montréal, QC, Canada. Electronic address: gagner.michel@gmail.com.
authors.forename: Michel
authors.initials: M
authors.lastname: Gagner
authors.affiliation: Division of Scientific Research Writing, Medwrite Medical Communications, Maiden Rock, WI, U.S.
authors.forename: Jane N
authors.initials: JN
authors.lastname: Buchwald
mesh_terms: D057868:Anastomotic Leak / Q000209:etiology / Q000517:prevention & control*; D005743:Gastrectomy / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D009767:Obesity, Morbid / Q000601:surgery*; D017792:Surgical Stapling / Q000379:methods*; D013537:Sutures
keywords: Bariatric; LSG; Laparoscopic sleeve gastrectomy; Leak; Metabolic; Reinforcement; Staple line; Systematic review