Suture reinforcement versus no reinforcement in laparoscopic sleeve gastrectomy: what do randomized trials show? A meta-analysis and trial sequential analysis

Purpose: 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. Materials and methods: 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. Results: 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). Conclusions: 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.