Seamguard Buttressing (SGB) and Oversewing/Suturing (OS/S) of the Staple Line in Sleeve Gastrectomy Appear to be Associated with Comparable Postoperative Outcomes. A Meta-Analysis of 11 Studies Comparing Two Effective Reinforcement Methods.

doi:10.21203/rs.3.rs-2575318/v1

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Seamguard Buttressing (SGB) and Oversewing/Suturing (OS/S) of the Staple Line in Sleeve Gastrectomy Appear to be Associated with Comparable Postoperative Outcomes. A Meta-Analysis of 11 Studies Comparing Two Effective Reinforcement Methods.

https://doi.org/10.21203/rs.3.rs-2575318/v1

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Postoperative staple line hemorrhage and leakage are major causes of postoperative morbidity after laparoscopic sleeve gastrectomy (LSG). Many staple line reinforcement (SLR) techniques have been innovated in efforts to reduce such complications; these include oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. Therefore, surgeons are often confused of which SLR they should use. Recent high-quality evidence shows that Seamguard buttressing (SGB) and OS/S are associated with better postoperative outcomes when each is compared to no SLR; having said that, it is unknown if one of these 2 methods is superior to the other. The aim of this study is to compare postoperative outcomes between LSG with SGB versus LSG with OS/S.

Key points

• No significant difference in postoperative bleeding, postoperative leakage, and readmission was observed between SGB and OS/S.

• SGB was associated with decreased incidence of reoperations, and without significant heterogeneity which makes the decrease generalizable. However, when compared to OS/S, number need to treat (NNT) with SGB to prevent a case reoperation is 166.

• OS/S was associated with shorter LOS, but this isn’t generalizable because of significant heterogeneity.

Per the World Health Organization (WHO), obesity is an epidemic and is a major health concern despite being preventable. The number of adults with obesity (defined by a body mass index > 30 kg/m²) is more than 650 millions across the globe (1). Obesity is associated with many comorbidities as diabetes mellitus (DM), dyslipidemia, hypertension (HTN), coronary artery disease (CAD) (2–5). Bariatric and metabolic surgery is the only curative medical option for managing obesity and its related diseases. Among the current surgical options available, laparoscopic sleeve gastrectomy (LSG) has become an accepted first-line surgery.

The American Society for Metabolic and Bariatric Surgery (ASMBS) in 2012 has endorsed LSG as a first-line bariatric surgical option (6). This position statement was based on extensive literature review on LSG, which demonstrated its success in weight loss, improvement and resolution of comorbidities, and enhancing quality of life. Having said that, LSG isn’t without complications that might be life threatening as postoperative staple line bleeding and leaks (7–9). There is ongoing research to refine LSG technique, and one of the proposed technical strategies to reduce complications is staple line reinforcement (SLR). Potential SLR options include oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. Two recent meta-analyses (10, 11) have clearly demonstrated the efficacy of Seamguard buttressing (SGB) and oversewing/suturing (OS/S) in the prevention of postoperative staple line bleeding and leaks, when each is compared to no SLR group (control). Having said that, it is currenly unclear if one of these 2 methods (SGB and OS/S) is superior to the other. Therefore, the goal of our study is to review the current literature in a quantitative fashion (meta-analysis) to evaluate if one method is better than the other.

Study Design and Search Strategy

We conducted a literature search in a systematic fashion and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Fig. 1). We used a combination of the following search terms: “sleeve gastrectomy”, “staple line reinforcement”, “oversewing”, “suturing”, “buttressing”, “Gore”, “Seamguard”, “absorbable polymer membrane”, “polyglycolic acid”, and “trimethylene carbonate”.

Eligibility Criteria

Studies were included if they (1) were comparative studies, (2) included patients who underwent LSG, and (3) compared LSG with Seamguard buttressing (SGB) versus LSG with oversewing/suturing (OS/S).

Data Extraction

For each included study, we identified the number of patients and the following outcomes (if available): Operative time, postoperative bleeding events, postoperative leak events, length of stay (LOS), readmissions, and reoperations.

Quality Assessment of randomized controlled trials

Cochrane collaboration tool was used to assess methodological quality and risk of bias in the included studies. This tool involves the use of 7 criteria as follows: (1) Random sequence generation (selection bias), (2) allocation concealment (selection bias), (3) blinding of participants and personnel (performance bias), (4) blinding of outcome assessment (detection bias), (5) incomplete outcome data (attrition bias), (6) selective outcome reporting (reporting bias), and (7) other bias. For each category, studies were classified as low, unclear, or high risk of bias.

Quality Assessment of nonrandomized cohort studies

A widely accepted and used tool is called the Newcastle-Ottawa Scale (NOS), was utilized in assessing the risk of bias in each included study (12). We assessed in each study 3 domains consisting of a total of 8 items. All items can be graded as 1 mark maximum except for the comparability item (5th item) which can be graded as 2 marks maximum. Maximum score is 9, a study with a score of 7–9 is a high-quality study, 4–6 is a study with a high risk of bias, 0–3 is a study with a very high risk of bias. The 3 domains and 8 items are as follows: (A) Selection domain (4 marks maximum): Item 1, representativeness of the SGB and OS/S cohorts of the general bariatric population; item 2, consistency in the selection of the SGB cohort in comparison with the selection of the OS/S cohort (the 2 cohorts weren’t drawn from different sources); item 3, ascertainment of exposure to either SGB or OS/S intervention in each cohort; and item 4, demonstration that the outcomes of interest were not present at the start of the study. (B) Comparability domain (2 marks maximum): Item 5, adjustment/control for important confounding factors (matching and/or multivariate analysis were done). (C) Outcome domain (3 marks maximum): Item 6, reliability of method of assessment of outcomes; item 7, adequacy of follow-up duration for outcomes to occur; and item 8, adequacy of the number of patients fulfilling the adequate follow-up duration.

Data Synthesis

Data were analyzed using the Review Manager (RevMen) 5.4.1 software. The random effects model was used in all meta-analyses because we considered that all studies are different from each other regardless of the I² value, and to enhance the generalizability of our findings. This was per the recommendations by scientific authorities in the field of meta-analysis (13, 14). For dichotomous data, odds ratio (OR) was used as the effect size. For continuous data, mean difference (MD) was used as the effect size. All values were reported with their corresponding 95% confidence intervals (CI). A p-value of less than 0.05 was considered as statistically significant for the pooled data. I² was used to characterize heterogeneity among studies.

Literature search results (Fig. 1)

Following the PRISMA guidelines of literature reviewing (Fig. 1), initial search identified 292 records. These records were screened and 235 were found clearly irrelevant and thus were excluded. Then the remaining 57 reports were sought for retrieval, and all were successfully retrieved and then assessed for eligibility. Then 46 reports were excluded following in-depth assessment because they were one of the following: Studies comparing between SLR arms other than specifically SGB vs OS/S (15 reports), one arm studies (13 reports), review articles (4 reports), how I/we do it articles (2 reports), studies in which the buttressing group wasn’t stratified to Seamguard buttressing and bovine pericardial strips buttressing (2 reports), studies comparing between arms not related to SLR (2 reports), or others (8 reports). Finally, 11 studies were included in this meta-analysis paper.

Study characteristics and baseline demographics (Table 1)

Included studies were either randomized controlled trials (4 studies) or nonrandomized cohort studies (7 studies). Baseline demographics of patients in the SGB and the OS/S arms in each study as number of patients (sample size), male to female ratio, mean age, and baseline BMI at bariatric surgery (BS); are summarized in Table 1 for randomized controlled trials (RCTs), and Table 2 for nonrandomized cohort studies.

Table 1

General characteristics and baseline demographics; randomized controlled trials
Study	Country	Low risk of bias score^a	Sample size		Gender (M/F)		Age (YO)		BMI at BS
Study	Country	Low risk of bias score^a	SGB	OS/S	SGB	OS/S	SGB	OS/S	SGB	OS/S
Albanopoulos 2012 (15)	Greece	7 / 7	48	42	19/29	18/24	37.6	37.9	46.08	47.4
Dapri 2010 (16)	Belgium	4 / 7	25	25	11/14	17/8	39.4	41.3	49.7	47.7
Gentileschi 2012 (17)	Italy	4 / 7	40	40	6/34	5/35	44.1	44.6	47	47.2
Prathanvanich 2015 (18)	USA	2 / 7	16	14	3/13	2/12	47.88	42.29	49.61	47.14
^a Cochrane collaboration tool was used to assess 7 elements (7 bias types) in each study. The low risk of bias score represents the number of elements (bias types) for which a study was judged to be low risk. SGB Seamguard buttressing, OS/S oversewing/suturing, M male, F female, YO year-old, BMI body mass index, USA United States of America.

Table 2

General characteristics and baseline demographics; nonrandomized cohort studies
Study	Country	Study design	Quality score^a	Sample size		Gender (M/F)		Age (YO)		BMI at BS
Study	Country	Study design	Quality score^a	SGB	OS/S	SGB	OS/S	SGB	OS/S	SGB	OS/S
Fort 2021 (19)	Spain	Retrospective	9 / 9	100	100	37/63	42/58	46.3	45.4	47.9	46.1
Barreto 2015 (20)	USA	Retrospective	8 / 9	860	373	254/606	104/373	46.1	46.2	49.6	50.5
D’Ugo 2014 (21)	Italy	Retrospective	8 / 9	63	476	16/47	124/352	47.1	44.6	45	46
Contreras 2016 (22)	Chile	Prospective	8 / 9	546	594	NR	NR	NR	NR	NR	NR
Polega 2015 (23)	USA	Retrospective	7 / 9	42	475	NR	NR	48.8	45.7	49	50.2
VanderVennen 2015 (24)	USA	Retrospective	7 / 9	817	445	NR	NR	48.7	45.7	47.2	48.7
Guerrier 2018 (25)	USA	Retrospective	8 / 9	115	28	NR	NR	NR	NR	NR	NR
^a Quality score of each study is measured according to the New-Ottawa Scale (NOS). SGB Seamguard buttressing, OS/S oversewing/suturing, M male, F female, YO year-old, BMI body mass index, BS bariatric surgery, USA United States of America, NA not applicable, NR not reported.

Quality assessment results for the RCTs (Fig. 2)

Quality assessment results as judged by authors are available for all these studies (Fig. 2). Three studies were judged to have unclear risk of selection bias due to lack of information about random sequence generation and/or allocation concealment. The remaining study was judged to have low risk of selection bias. Regarding performance and detection bias, 3 studies were judged to have unclear risk of both performance bias and detection bias, while the remaining 1 study was judged to have low risk of both performance bias and detection bias. Regarding attrition bias and reporting bias, all studies were judged to have low risk of bias. For the other bias category, 3 studies were judged to have low risk of bias, while the remaining 1 study was judged to have unclear risk of bias.

Quality assessment results for the nonrandomized cohort studies (Table 2)

Out of seven studies, two had a score of 7 out of 9, four had a score of 8 out of 9, and 1 study had a score of 9 out of 9. Therefore, all studies were judged to be high quality studies per the Newcastle-Ottawa Scale (NOS).

Meta-analysis for mean operative time in minutes

Operative time was reported in 4 RCTs, 129 in the SGB group vs 121 in the OS/S group. In these studies, statistically significant decrease in operative time with SGB was observed (MD -13.92, 95% CI -19.14 – -8.70, p < 0.00001). I² was 91% (p < 0.00001).

Operative time was reported in 2 nonrandomized cohort studies, 215 in the SGB group vs 128 in the OS/S group. In these studies, statistically insignificant decrease in operative time with SGB was observed (MD -15.00, 95% CI -32.74–2.74, p < 0.10). I² was 76% (p = 0.04).

Meta-analysis for postoperative bleeding events (Fig. 3)

Postoperative bleeding events were reported in 2 RCTs, 88 in the SGB group vs 82 in the OS/S group. In these studies, statistically insignificant increase in postoperative bleeding events with SGB was observed (1.53, 95% CI 0.18–12.72, p = 0.69). I² was 0% (p = 0.65) (Fig. 3A).

Postoperative bleeding events were reported in 6 nonrandomized cohort studies, 2443 in the SGB group vs 2391 in the OS/S group. In these studies, statistically insignificant increase in postoperative bleeding events with SGB was observed (1.14, 95% CI 0.58–2.23, p = 0.71). I² was 16% (p = 0.31) (Fig. 3B).

Meta-analysis for postoperative leak events (Fig. 4)

Postoperative leak events were reported in 3 RCTs, 113 in the SGB group vs 107 in the OS/S group. In these studies, statistically insignificant increase in postoperative leak events with SGB was observed (OR 1.61, 95% CI 0.31–8.41, p = 0.57). I² was 0% (p = 0.49) (Fig. 4A).

Postoperative leak events were reported in 7 nonrandomized cohort studies, 2543 in the SGB group vs 2491 in the OS/S group. In these studies, statistically insignificant decrease in postoperative leak events with SGB was observed (OR 0.82, 95% CI 0.40–1.66, p = 0.57). I² was 0% (p = 0.93) (Fig. 4B).

Meta-analysis for mean LOS in days (Fig. 5)

Mean LOS (days) was reported in 2 RCTs, 73 in the SGB group vs 67 in the OS/S group. In these studies, statistically significant increase in mean LOS with SGB was observed (MD 0.86, 95% CI 0.37–1.34, p = 0.0006). I² was 5% (p = 0.30) (Fig. 5A).

Mean LOS (days) was reported in 4 nonrandomized cohort studies, 1819 in the SGB group vs 1393 in the OS/S group. In these studies, statistically insignificant increase in LOS with SGB was observed with SGB (MD 0.22, 95% CI -0.00–0.45, p = 0.05). I² was 90% (p < 0.00001) (Fig. 5B). Although statistically insignificant, the p value of 0.05 is exactly on the predetermined significance cutoff (p < 0.05). This with the statistically significant increase in LOS with SGB in randomized controlled trials, can allow us to consider the increase in LOS with SGB in nonrandomized cohort studies as statistically significant from the realistic point of view. Having said that, the heterogeneity observed among studies as observed by I² and 95% prediction interval plot (Fig. 5C); limit generalizability of this finding. As shown in the plot (Fig. 5C), SGB will increase the LOS in most patients (the part of the plot right the the zero), but it will decrease the LOS in a minority of patients (part of the plot left to the zero).

Meta-analysis for readmission events (Fig. 6)

Readmission events were reported in 3 RCTs, 113 in the SGB group vs 107 in the OS/S group. In these studies, statistically insignificant increase in readmissions with SGB was observed (OR 2.08, 95% CI 0.36–11.89, p = 0.41). I² was 14% (p = 0.31) (Fig. 6A).

Readmission events were reported in 4 nonrandomized cohort studies, 1834 in the SGB group vs 1321 in the OS/S group. In these studies, statistically insignificant increase in readmissions with SGB was observed (OR 1.38, 95% CI 0.77–2.47, p = 0.28). I² was 0% (p = 0.82) (Fig. 6B).

Meta-analysis for reoperation events (Fig. 7)

Reoperation events were reported in 2 RCTs, 73 in the SGB group vs 67 in the OS/S group. In these studies, statistically insignificant increase in reoperations with SGB was observed (OR 2.89, 95% CI 0.29–28.56, p = 0.36). I² was 0% (p = 0.95) (Fig. 7A).

Reoperation events were reported in 5 nonrandomized cohort studies, 1620 in the SGB group and 1642 in the OS/S group. In these studies, statistically significant decrease in reoperations with SGB was observed (OR 0.33, 95% CI 0.13–0.79, p = 0.01). I² was 0% (p = 0.47) (Fig. 7B). Due to minimal heterogeneity among studies, and the fact that random effects model was used in analysis, the statistically significant decrease in reoperations is a generalizable finding. However, when compared to OS/S, number needed to treat (NNT) with SGB to prevent a single case of reoperation is 166 patients.

Despite of the advances in staplers’ technology, postoperative staple line bleeding and leakage persist as the most feared post-LSG complications to surgeons (26). In addition, LSG is associated with long-term complications as gastroesophageal reflux disease (GERD), Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) (27). Furthermore, emerging evidence in the literature shows that bariatric and metabolic surgery might be a cause to gastrointestinal dysmotility (28). Due to the fact that postoperative staple line bleeding and leaks, and EAC are life threatening, some authors claim that bariatric intragastric balloon (IGB) placement is a safer alternative to LSG (29). IGB isn’t associated with similar weigh loss profiles as those observed with LSG. In addition, IGB has its complications too as IGB induced pancreatitis, gastric outlet obstruction (antral impaction), and bowel obstruction (29–31).

Many surgeons do SLR during LSG to reduce postoperative bleeding and postoperative leaks. However, some argue against the use of SLR due to high cost of buttressing and gluing and lack of sufficient weight of high quality evidence that proves that it results in better outcomes (32–34). On the other hand, 2 recent meta-analyses (10, 11) have demonstrated clear benefits of SGB and OS/S in preventing postoperative adverse outcomes when each is compared to no-SLR. Furthermore, the International Sleeve Gastrectomy Expert Panel recommends the usage of SLR routinely. All the members of the panel without exceptions agreed that SLR would reduce postoperative staple line bleeding (35). However, standardization of SLR is still lacking due to the absence of a clear advantage of one method over the other.

Postoperative leaks and bleeding

Leaks has two etiologies: Mechanical and ischemic. Mechanical leaks occur within 48–72 hours postoperatively and are mainly due to unsuitable size staple size or operative mistakes, errors, or injuries. Ischemic leaks on the other hand occur 5 days after surgery and are likely due to distal obstruction (36). Having said that, a study has found by microdialysis and by measuring glycerol, pyruvate, and lactic acid levels, that ischemia might not be a genuine etiology for postoperative staple line leak development. Authors of this study think that postoperative leaks are due to the high intraluminal pressure that develops in the remnant stomach following LSG, and thus it is of mechanical rather than ischemic etiology (37). The esophagogastric junction is a common site for postoperative leakage, a reason could be that the gastric wall at the esophagogastric junction is thin and thus less resistant to the elevated intraluminal pressure of the remnant stomach following LSG (21). Regarding postoperative bleeding, there is no standard definition for it in the literature, a flexible definition is any postoperative bleeding regardless of its severity, volume, or the necessity for transfusion (38, 39). A strict definition on the other hand is a postoperative bleeding that required transfusion (21, 40, 41). No significant differences were observed between OS/S and SGB groups in postoperative bleeding and leaks. This is despite that the sample size used to analyze these 2 outcomes in the nonrandomized cohort studies was large: > than 2000 patients in each arm. These 2 findings are confirmed with the lack of statistically significant difference in readmissions between OS/S and SGB. However, the statistically significant difference in reoperations isn’t consistent with the absence of difference in the previously mentioned 3 outcomes (bleeding, leaks, and readmissions); thus, we tried to review in-depth the causes of reoperations in the OS/S groups in all the included studies and didn’t reach a conclusion.

Does the decrease in reoperations worth the additional cost of Seamguard buttressing (SGB)?

A study in Greece (15) have found that the cost of LSG without any SLR is 4600 euros, while the cost of LSG with total SGB along the whole staple line is 6880 euros as one stapler load with SGB costs 380 euros (in Greece). A study in Belgium (16) have found that the additional cost of SGB use per procedure ranged between 640 euros (5 stapler load) to 896 euros (7 stapler load), as one staple load with Seamguard buttress material costs 128 euros (in Belgium). A study in Italy (17) compared the mean additional costs of SLR per patient in the OS/S and the SGB groups, they found that the mean additional cost in the OS/S group was 8 euros, while it was 580 euros in the SGB group. A study in the USA (24) compared mean additional costs of SLR per patient in the OS/S and the SGB groups, they found that the mean additional costs in the OS/S group was 5 dollars, while it was 787 dollars in the SGB group.

When compared to OS/S, the number needed to treat (NNT) with SGB to prevent a single case of reoperation is 166. It is very clear from the financial perspective that dealing with a single case of reoperation would be much cheaper than using SGB in 166 patients, especially that OS/S according to our study would likely decrease the LOS in most patients (not all of them due the significant heterogeneity level observed among studies as mentioned previously). Therefore, our paper doesn’t support the use of SGB from the financial perspective; and thus, we recommend OS/S in developing countries where SGB isn’t affordable, but in developed nation with rich health systems, SGB have few advantages that need to be taken into consideration: (A) We are talking here about reoperations that were done due to a serious situation; therefore, preventing a life-threatening situation every 166 patients is something we consider important. Our opinion can be supported by the estimate of the number of LSG procedures done annually, this estimate is 150,000 and 350,000 procedures in the USA and worldwide, respectively (42). Therefore, SGB might prevent lots of life-threatening situations from the larger perspective. (B) Unlike with OS/S, SGB doesn’t require additional operative time. (C) SGB use is standardized unlike with OS/S which is done as reported in the literature using different suture types and suturing techniques. One can reasonably argue that different suture types and techniques would lead to different postoperative outcomes, and we don’t know yet what is the best OS/S technique, which would limit its use by some surgeons. (D) According to a recent meta-analysis of randomized controlled trials comparing between OS/S and no SLR (10), OS/S was associated with a statistically significant increase in the incidence of prolonged vomiting following LSG, without any heterogeneity among studies making this finding generalizable. We think that this might be related to a degree of sleeve stenosis/stricture; having said that, the same meta-analysis didn’t find any difference between OS/S and no SLR in incidence of sleeve stenosis/stricture, which might be due to the different definitions physicians use to define/diagnose a case of sleeve stenosis/stricture. In other words, the lack of difference between OS/S and no SLR in that meta-analysis is possibly due to that many cases of prolonged vomiting which were significantly higher in the OS/S group; might have been due to sleeve stenoses/strictures that weren’t diagnosed. Indeed, 2 comparative studies in the literature have findings that suggest that OS/S might increase the risk of sleeve stenosis/stricture: (1) Musella et al. 2011 RCT (43) found a statistically significant increase in the incidence of sleeve stenosis/stricture with OS/S when compared to no SLR. (2) Guerrier et al. 2018 (25) study compared between SGB and OS/S and found a statistically significant increase in the incidence of sleeve stenosis/stricture with OS/S (p = 0.0039). Therefore, the use of SGB might prevent the morbidity of OS/S induced prolonged vomiting, and potentially sleeve stenosis/stricture.

Limitations

This study has few limitations: Most of the studies on which this meta-analysis was based on were nonrandomized cohort studies (7 studies), only 4 were RCTs. In addition, the pooled sample provided by the RCTs is very small. Another limitation is that SLR in the OS/S pooled cohort involved the use of variable suturing techniques and variable suture types, and thus one can reasonably argue that one technique and/or suture type might produce better postoperative outcomes and thus would be a better competitor to SGB and would allow for fairer comparison.

SGB and OS/S appear to have similar efficacy in preventing readmissions, and postoperative leaks and postoperative bleeding of the staple line. Although SGB requires less operative time when compared to OS/S, its use is more expensive. Regarding LOS and reoperations outcomes, one is better with OS/S (LOS) and the other is better with SGB (reoperations). However, the basis of evidence for these 2 outcomes (LOS and reoperations) is not of equal strength. The shorter LOS with OS/S was associated with significant heterogeneity among studies which limit generalizability. On the other hand, the lower incidence of reoperations with SGB wasn’t associated with significant heterogeneity. This with the use of random-effects model in this meta-analysis paper; make this finding (decreased reoperations with SGB) generalizable and based on strong evidence. When compared with OS/S, the number needed to treat (NNT) with SGB to prevent a case of reoperation was 166 patients. The cost of using SGB in 166 patients is much more expensive than the cost of a single case of reoperation with its associated preoperative and postoperative morbidity. Therefore, in developing nations, we recommend OS/S, especially that it would decrease LOS in most patients. In other words, OS/S is likely much more cost-effective. But in developed countries where SGB is affordable, we feel hesitant to recommend one method over the other, but we acknowledge that the use of SGB instead of OS/S has valuable advantages (as mentioned in the discussion). Larger multi-center randomized controlled trials and large cost-analysis studies are warranted to decide the optimal method in developed countries. Therefore, we don’t recommend at this stage one method over the other in developed countries, unlike with developing countries where we recommend OS/S or any other SLR method that is affordable and of equal efficacy; this method might be the omentopexy/gastropexy (OP/GP) method but studies are needed as well.

Conflict of Interest: No conflict of interest.

Ethical Approval: This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent: Informed consent does not apply.

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Seamguard Buttressing (SGB) and Oversewing/Suturing (OS/S) of the Staple Line in Sleeve Gastrectomy Appear to be Associated with Comparable Postoperative Outcomes. A Meta-Analysis of 11 Studies Comparing Two Effective Reinforcement Methods.

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Abstract

Figures

Introduction

Methods

Study Design and Search Strategy

Eligibility Criteria

Data Extraction

Quality Assessment of randomized controlled trials

Quality Assessment of nonrandomized cohort studies

Data Synthesis

Results

Study characteristics and baseline demographics (Table 1)

Quality assessment results for the RCTs (Fig. 2)

Quality assessment results for the nonrandomized cohort studies (Table 2)

Meta-analysis for mean operative time in minutes

Meta-analysis for postoperative bleeding events (Fig. 3)

Meta-analysis for postoperative leak events (Fig. 4)

Meta-analysis for mean LOS in days (Fig. 5)

Meta-analysis for readmission events (Fig. 6)

Meta-analysis for reoperation events (Fig. 7)

Discussion

Postoperative leaks and bleeding

Does the decrease in reoperations worth the additional cost of Seamguard buttressing (SGB)?

Limitations

Conclusion

Declarations

References

Supplementary Files

Status:

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