Staple-line Suture Reinforcement: Could it Help Contain the Leak?
Conditions: Bariatric Surgery Candidate, Obesity, Morbid, Leak, Anastomotic, Bleeding
Sponsor: University of Foggia

STAPLE-LINE SUTURE REINFORCEMENT: 
COULD IT HELP CONTAIN THE LEAK? 
 
NCT Number: not available  
 
Date of document: 02/08/2023  
 
 
 
 
 
 
 
 

 
 
 
 
 
ABSTRACT 
 
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed 
bariatric procedure. The most fearsome complications are leaks and bleeding from the suture line. 
Staple line reinforcement (SLR) has been suggested as a mean of reducing the risk of sleeve leakage 
or bleeding. The aim of this study is to analyze if the suture reinforcement can be employed to 
reduce the leakage rate after sleeve gastrectomy. 
MATERIALS AND METHODS:  A total of 100 patients undergoing LSG between January and December 
2022 at the University Hospital of Foggia, all performed and treated by the same experienced 
surgeon, were retrospectively assessed; the reinforcement  technique was applied in 98 patients at 
the upper third of the staple line with barbed sutures (Suture Group). We compared these data with 
a group of 71 patients (Control Group) undergoing LSG between January and December 2021 
without the employment of reinforcement technique. 
RESULTS: The study gathered 171 patients, 98 for the Suture Group and 73 for the Control Group. 
The study includes 61 males (35,7 %) and 110 (64,3 %) females, with a mean age of 36,8 ± 12,2 years 
(range: 18-65 years) and a mean body mass index of 47,5 ±  9,3 kg/m2. The mean operative time for 
the Suture Group was 53,9 ± 6,3 minutes and 46,5 ± 8,2 minutes for the Control Group (p-value > 
0,05). The upper third of the staple line  was reinforced with barbed suture and postoperative 
leakage occurred in 1 patient (1 %) belonging to the Suture Group; in the Control Group we observed 
3 cases of leak (4,1 %).  

CONCLUSIONS: The literature does not provide sufficient evidence to support the routinary use of 
suture-reinforcement techniques in laparoscopic sleeve gastrectomy, but our study highlighted a 
lower leakage rate in the group featured by the suture reinforcement. The collected data are still 
small, therefore it is necessary to continue the study to obtain more significant results. 
 
 
 
 
 
 
Keywords: suture reinforcement; sleeve gastrectomy, leak; gastric fistula; bleeding; bariatric 
surgery. 
INTRODUCTION 
 
Obesity is a complex and highly prevalent chronic disease representing a major public health 
concern [1]. 
Laparoscopic sleeve gastrectomy (LSG) is a surgical weight loss procedure in which about three-
quarters of the stomach is removed, leaving behind a narrow gastric tube or sleeve. In recent years, 
LSG has become one of the preferred surgical modalities for the treatment of obesity [2, 4]. Not 
only is this surgery safe in terms of mortality, but it also offers long-term weight loss with the added 
benefit of resolving or improving obesity-related comorbidities [3]. 
The major early postoperative complications of leakage and bleeding are low probability events, but 
have devastating outcomes and a frustrating impact on patient recovery, hospital stay and medical 
costs [5,6] . Bleeding after LSG is reported at an average rate of 2% and might occur when dividing 
the greater curvature vessels or when suturing the stomach [7]. 
Gastric leakage is the most feared complication of GS due to its complex management and its clinical 
evolution, which can be particularly long. Lasting up to 90% of LSG leaks occur at the 
esophagogastric junction (EGJ) rarely involving the distal part of the suture line [8]. The leak rate is 
reported as 2.2%–2.4% according to two large systematic reviews in literature [9]. 
Despite the similar basic principles of LSG, technical variations exist among surgeons. Debates 
concerning the need for staple line reinforcement (SLR) after LSG and its methodologic features 
continue. 

Intraoperative manipulation of the suture line is greatly important in order to prevent or reduce 
these serious and feared complications [10]. Approximately 80% of surgeons prefer the SLR, but 
their methods have shown a variety, including buttress, overstitch, inversion of the suture and 
omental tape [11]. 
The aim of this study is to analyze if the suture reinforcement can be used to reduce the leakage 
rate after sleeve gastrectomy. 
 
MATERIALS AND METHODS 
 
A total of 100 patients undergoing LSG between January and December 2022 at the University 
Hospital of Foggia, all performed and treated by the same experienced surgeon, were 
retrospectively assessed; the reinforcement  technique was applied in 98 patients at the upper third 
of the staple line with barbed sutures (Suture Group). We compared these data with a group of 71 
patients (Control Group) undergoing LSG between January and December 2021 without the 
employment of reinforcement techniques. 
 
Eligibility criteria  
 
Adult patients of both sexes aged between 18 and 65 years with morbid obesity defined as 
BMI>40 kg/m2or BMI>35 kg/m2with at least one associated major comorbidity were included and 
were subjected to laparoscopic Sleeve Gastrectomy. We excluded patients with secondary obesity 
due to endocrine and  psychological disorders, patients under antiaggregant and anticoagulant 
therapies and re-do surgery. 
 
Statistical analysis  
 
Continuous data were expressed as mean and standard deviation (SD) and they were analyzed 
with Chi-square test with a p value less than 0,05 (p<0,05) for statistical significance. 
 
Surgical Technique 
 

The technique involves the use of 4 12 mm trocars. Pneumoperitoneum is induced by a 0° optical 
trocar and maintained at 15 mmHg. The first trocar is usually inserted along the left mid-clavicular 
line approximately 3 fingers from the costal arch, another trocar along the left axillary line, a third 
trocar 1 cm to the right of the midline, and the fourth trocar along the right mid-clavicular line. A 10 
mm, 30 ° laparoscope is used. 
The left lobe of the liver is retracted to expose the lesser gastric curvature and the gastroesophageal 
junction. The procedure begins by dissecting the small branches of the gastroepiploic arch 6 cm 
from the pylorus. The dissection continues along the great curvature of the stomach, remaining very 
close to the gastric wall, up to the short gastric vessels which are also dissected. The stomach is then 
raised to expose its posterior wall and the adhesions are lysed. His angle is fully mobilized and the 
left diaphragmatic pillar are exposed. The gastric tubule is created according to the guide provided 
by 40 F Bougie using mechanical suturing machines with cartridges of different thickness depending 
on the thickness of the gastric wall. At this point the bougie is removed and the resected stomach 
is extracted from the abdomen through the mesogastric access. 
In Suture Group, we applied running seromuscular stitches at the proximal third of the stapled line 
using unidirectional 2/0 barbed sutures to invaginate the staple line completely.  
The pneumoperitoneal pressure of CO2 is reduced to 8 mmHg and the haemostasis is assessed. In 
case of bleeding we proceeded cauterizating with monopolar forceps or employing laparoscopic 
hemostatic agents. Abdominal drainage is placed. 
 
 
RESULTS 
 
The study gathered 171 patients, 98 for the Suture Group and 73 for Control Group. 
The study includes 61 males (35,7 %) and 110 (64,3 %) females, with a mean age of 36,8 ± 12,2 years 
(range: 18-65 years) and a mean body mass index of 47,5 ±  9,3 kg/m2 (Table 1). The mean operative 
time for the Suture Group was 53,9 ± 6,3 minutes while for the Control Group was 46,5 ± 8,2 minutes 
(p-value > 0,05). The upper third of the staple line  was reinforced with barbed suture and this Group 
postoperative leakage was featured by 1 patient (1 %); the Control Group expressed 3 cases of leak 
(4,1 %) (Table 2).  
 
 

Table 1: Preoperative characteristics and comorbidities of the study groups  
 
Suture Group  
Control Group 
Age (years) mean ± (SD)  
45,1 ± 8,4  
44,5 ± 9,2  
Female number (%)  
59 (60,2%) 
51 (69,9%) 
Preoperative BMI (kg/m2) mean 
± (SD)  
45,6 ± 6,71  
48,9 ± 7,15  
Type 2 diabetes number (T2D) 
(%) 
21 (21,4%) 
15 (20,5%) 
Hypertension number (HTN) (%) 72 (73,5%) 
62 (84,9%) 
SD: Standard Deviation 
 
 
 
 
Table 2: Operative characteristics of the study groups  
 
Suture Group  
Control Group 
p-value 
Operative Time (minutes) ± (SD)  53,9 ± 6,3 
46,5 ± 8,2 
0.3843 
Rate of conversions to open 
surgery  number (%) 
0 (0%) 
0 (0%) 
 
n.s. 
Leak number (%) 
1 (1%) 
3 (4,1%) 
n.s. 
SD: Standard Deviation 
 
DISCUSSION 
Laparoscopic sleeve gastrectomy (LSG) is the most commonly used bariatric surgery procedure and 
is preferred for reduction of comorbidities, and low complication rate. Serious complications 
associated with LSG include postoperative leak and suture bleeding. Most of the leaks and bleeding 
are related to the staple line, since 90% of the leaks occur in the proximal part of the gastric sleeve 
near the gastroesophageal (GE) junction. The most common site of bleeding is the staple line, and 
the strictures are most frequently near the incisura angularis [12-15]. This might be related to the 
configuration of the gastric pouch after sleeve gastrectomy, featuring a long tubular stomach 
remnant, linked to the development of high intraluminal pressure [16-17]. Moreover, the 

compliance of the gastric pouch is notably lower than the compliance of the complete stomach, 
therefore amplifying the intraluminal pressure [18]. High intraluminal pressure associated with the 
relative difference of tissue thickness between fundus (1.7 mm), gastric body (2.4 mm), and antrum 
(3.1 mm) makes the staple line at the angle of His more vulnerable and consequently the most prone 
to the leakage [19]. Leak secondary to ischemia usually occurs after 5 post-surgery days, while leaks 
occurring earlier are usually related to mechanical failure of the stapling technique distal 
obstruction [16]. 
In this study, we compared the invagination of the upper third of the staple line with continuous 
running seromuscular stitches using barbed sutures, to the group without barbed suture. 
Barbed suture allows knotless tissue approximation and requires less effort and time than 
conventional barbed sutures because it does not need to be repeatedly retensioned during the 
apposition. It is potentially safer and has a higher burst pressure in comparison with barbless 
monofilament. 
Operative time was longer in Suture group, with a mean operative time of 53,9 ± 6,3 min, while the 
Control group was characterized by 46,5 ± 8,2 min. The difference in timing is not statistically 
significant. 
Leak occurred in three cases (4,1%) in the Control group and one (1%) in Suture group.  
Varban et al. [20] observed  that oversewing the staple line was the only technique-specific factor 
associated with lower leaks. 
Aggarwal et al. [21] compared staple line oversewing by invaginating sutures with no intervention 
techniques over a 60-patient cohort study reporting a lower leak rate in the oversewing group. 
Casella et al. [22] performed staple line oversewing using 2-0 polydioxanone in 100 cases over a 
total of 200 patients. They reported two leaks in the suture group and four leaks in the other 100 
cases. They considered that oversewing cannot eliminate leak but can diminish it. 
Bülbüller et al. [23] performed a prospective study to compare different staple line reinforcement 
(SLR) techniques in LSG; 65 patients were included and were randomized into four groups: group 1 
(15 patients) had no SLR, group 2 (16 patients) had SLR by continuous imbricating 3-0 prolene 
sutures, group 3 (16 patients) had SLR by imbricating 3-0 V-Loc 180 sutures and group 4 (18 patients) 
had SLR by fibrin glue. They reported longer operative time with the prolene group with no 
significant differences in leak and bleeding between the different groups. 
Albanopoulos et al. [24] randomly enrolled 90 patients in a study to compare SLR by continuous 
imbricating sutures to SLR using absorbable polymer membrane in LSG. Group A (48 patients) had 

SLR by buttressing the staple line with Seamguard and group B (42 patients) had SLR by oversewing 
the staple line with 2-0 PDS sutures. They reported two cases of leak and one case of bleeding in 
group A with no complications in group B, still not providing statistical significance. 
D’Ugo et al. [25] performed a multicenter study over a total of 1162 patients undergoing LSG. The 
patients were enrolled into six groups: group 1 (189 patients) had no SLR done, group 2 (476 
patients) had SLR oversewing using continuous absorbable sutures, group 3 (312 patients) had SLR 
by buttressing using bovine pericardium strips, group 4 (76 patients) had SLR by buttressing using 
synthetic polyester, group 5 (63 patients) had SLR by buttressing using absorbable polymer 
membran and group 6 (46 patients) had reinforcement by applying hemostatic thrombin matrix. 
The frequency of bleeding was significantly higher in group 1 with no SLR, and frequency of leak was 
significantly lower in group 3 (SLR using bovine pericardium strips). 
Our results are in line with literature evidences, showing a reduction in leak rate in patients 
subjected to LSG with a staple line reinforcement with barbed suture, though this is not always 
statistically significant. 
 
 
 
CONCLUSION 
 
Current literature does not provide sufficient evidence to support the routinary use of suture-
reinforcement techniques in laparoscopic sleeve gastrectomy, but our study highlighted a lower 
leakage rate in the group featured by suture reinforcement.  
Further studies with larger sample size are needed to verify the preventive role of suture staple line 
reinforcement on postoperative leak rate.  
. 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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