Zhuang ZX, Zhang Y, Yang XY, Wang ZQ, Deng XB, Zhang MM. Efficacy of reinforcing sutures in preventing anastomotic leakage after surgery for rectal cancer: A systematic review and metaanalysis. World J Gastrointest Surg 2025; 17(5): 103758 [DOI: 10.4240/wjgs.v17.i5.103758]
Corresponding Author of This Article
Ming-Ming Zhang, Professor, Colorectal Cancer Center, Department of General Surgery, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan Province, China. zhangmm@scu.edu.cn
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Zi-Xuan Zhuang, Yang Zhang, Xu-Yang Yang, Zi-Qiang Wang, Xiang-Bing Deng, Ming-Ming Zhang, Colorectal Cancer Center, Department of General Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
Co-corresponding authors: Xiang-Bing Deng and Ming-Ming Zhang.
Author contributions: Zhuang ZX contributed to the design and implementation of the study and the writing of the manuscript; Zhang Y and Yang XY contributed to the statistical analyses and the writing of the manuscript; Deng XB contributed to the design of the study and the revision of the manuscript; Wang ZQ contributed to the performance of the research; Deng XB and Zhang MM contributed to the quality and professional revision, and contributed equally as co-corresponding authors; Zhang MM contributed to the quality and professional revision and the writing of the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ming-Ming Zhang, Professor, Colorectal Cancer Center, Department of General Surgery, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan Province, China. zhangmm@scu.edu.cn
Received: November 29, 2024 Revised: February 25, 2025 Accepted: March 24, 2025 Published online: May 27, 2025 Processing time: 174 Days and 22.3 Hours
Abstract
BACKGROUND
Anastomotic leakage (AL) is a challenging complication following rectal cancer surgery, often leading to increased morbidity and healthcare costs. The use of reinforcement sutures is expected to reduce the rate of AL, their preventive effects are controversial.
AIM
To determine the efficacy of reinforcing sutures in preventing AL in rectal cancer.
METHODS
A systematic search of major medical databases was conducted to identify studies up to June 2024. Intraoperative and postoperative outcomes were assessed; the primary outcome assessed was the incidence of AL. Pooled odds ratios (ORs) and mean differences (MDs) with a 95% confidence interval (CI) were calculated using fixed-effect or random-effect models under heterogeneity.
RESULTS
This meta-analysis incorporated 20 studies involving 3726 patients. Pooled results demonstrated a statistically significant reduction AL incidence in the reinforced suture group (OR: 0.26, 95%CI: 0.19-0.35, P < 0.001) than the unreinforced suture group. The reinforced suture group also exhibited a shorter hospital stay (MD: -1.17, 95%CI: -1.78 to -0.57, P < 0.001), earlier anal exhaust (MD: -0.13, 95%CI: -0.22 to -0.05, P = 0.002), longer operative time (MD: 15.25, 95%CI: 10.71-19.80, P < 0.001), lower infection rate (OR: 0.54, 95%CI: 0.29-1.00, P = 0.05) and lower reoperation rate (OR: 0.19, 95%CI: 0.08-0.45, P < 0.001).
CONCLUSION
The results substantiate the clinical value of anastomotic reinforcement sutures in reducing AL incidence post-rectal cancer surgery. Nevertheless, these conclusions warrant verification through additional high-quality randomized controlled trials.
Core Tip: This extensive systematic review rigorously evaluates the effectiveness and safety of trans-anal versus intracorporeal reinforcement sutures in low anterior resection for rectal cancer, offering the most robust methodological appraisal to date. Through heterogeneity assessment, sensitivity and subgroup analyses, and publication bias evaluation, it strengthens evidence quality, addresses outcome variability, and underscores clinical implications. Results inform surgical decision-making by comparing anastomotic leakage risks, postoperative morbidity, and technical feasibility, advocating for standardized practices to optimize colorectal surgical outcomes.
Citation: Zhuang ZX, Zhang Y, Yang XY, Wang ZQ, Deng XB, Zhang MM. Efficacy of reinforcing sutures in preventing anastomotic leakage after surgery for rectal cancer: A systematic review and metaanalysis. World J Gastrointest Surg 2025; 17(5): 103758
Rectal carcinoma represents a predominant gastrointestinal malignancy globally, with radical resection constituting the cornerstone of contemporary therapeutic strategies[1]. Despite advancements in minimally invasive techniques, widespread adoption of neoadjuvant therapies, and innovations in stapled anastomosis technology, anastomotic leakage (AL) persists as a major concern in rectal cancer surgery. AL predisposes patients to acute complications [longer hospital length of stay, elevated surgical site infections (SSIs), and bowel dysfunction] while correlating with reduced quality of life, elevated local recurrence risks, and compromised disease-specific survival[2,3]. Current evidence indicates AL incidence rates of 3%-28% with associated mortality ranging from 6%-30%[4-6], underscoring the critical need for effective preventive measures in mid-low rectal resections. Diverting stoma, while commonly employed to protect anastomotic integrity and mitigate AL severity, remains controversial due to necessitating secondary surgical procedures and frequent stoma-related complications that significantly increase patient/caregiver burden and impair quality of life[7,8]. Trans-anal drainage tube placement represents another preventive approach aimed at reducing intraluminal pressure. Although some evidence suggests trans-anal drainage tube placement may decrease Grade C leakage rates, its clinical utility remains debated[9].
Current research identifies three primary AL determinants: Surgical technique selection, anastomotic blood supply adequacy, and anastomotic tension presence[10-12]. Among these factors, the anastomotic technique and instruments were assumed to play a pivotal role. The double-stapled anastomosis is a widely applied technique; however, at least two staple lines cross each other in the double-stapled technique, forming a potential ischemic area known as a “dog ear”. Furthermore, stapler removal may cause traumatic tearing at the anastomotic site, particularly in these vulnerable areas, potentially compromising structural integrity[13,14]. Therefore, reinforcing the anastomotic site, especially the “dog ears” area, is considered helpful in reducing postoperative AL. Gadiot et al[14] pioneered the application of tri-quadrangular tension-reducing sutures in circular stapled anastomoses, demonstrating a 62% reduction in leakage incidence compared to conventional single-layer closure. Subsequent single-center randomized controlled trials (RCTs) and retrospective studies have further explored reinforcement suture outcomes, though multicenter prospective RCTs remain absent. Thus, we conducted this systematic review and meta-analysis to draw a preliminary conclusion about the effectiveness and safety of anastomotic reinforcement sutures as an alternative technique in preventing AL after rectal cancer surgery.
MATERIALS AND METHODS
Protocol registration
This systematic review follows the recommendations of the Assessing the methodological quality of systematic reviews guidelines[15] and adheres to the PRISMA reporting standards[16]. We followed a priori protocol registered at the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42024500080, https://www.crd.york.ac.uk/prospero/). All authors had access to the study data and reviewed and approved the final manuscript.
Literature search
The systematic search employed medical subject headings (MeSH) terms combined with text word strategies across eight databases (PubMed, Embase, Web of Science, Cochrane Library, Sinomed, Wangfang, VIP, China National Knowledge Infrastructure) through the Cochrane Collaborative Network. Search parameters incorporated controlled vocabulary (“anastomotic leak[MeSH]”) and free-text terms: (“anastomotic leakage” OR leak*) AND (“reinforcing suture” OR suture) AND (“rectal cancer” OR “rectal neoplasms” OR “rectal tumor”). Prospective trial registries (ClinicalTrials.gov, International Clinical Trials Registry Platform) and supplementary grey literature were interrogated, with search currency extended through June 2024.
Inclusion and exclusion criteria
Studies were included based on the following criteria: (1) Population comprising histologically confirmed rectal adenocarcinoma patients; (2) Original articles compared anastomotic suture reinforcement and not strengthened in laparoscopic rectal cancer resection; and (3) Availability of primary outcome data, including but not limited to AL incidence. Exclusion criteria comprised: (1) Non-primary research formats (systematic reviews, correspondence articles, case series); (2) Duplicate datasets (retaining most recent/Largest cohort); and (3) Unobtainable full-text documentation after interlibrary loan requests.
Study selection
Dual investigators independently screened retrieved records using predefined eligibility thresholds. Publications satisfying inclusion parameters underwent blinded full-text appraisal, with discrepancies resolved through iterative consensus-building or consultation with a third independent reviewer. Final inclusion validation strictly followed Population, Intervention, Comparison, Outcomes and Study design framework criteria.
Outcomes and definition
Two independent investigators conducted blinded data extraction from all eligible studies that applied the International Study Group of Rectal Cancer criteria for AL diagnosis. The studies employed diverse anastomotic reinforcement techniques (interrupted sutures, continuous sutures). These technical variations were systematically evaluated in subgroup analyses to assess their impact on outcomes, ensuring comparability across studies. The extracted data encompassed: First author, year of publication, country, study design, number of participants, number of cases, age, sex, body mass index, tumor-node-metastasis stage, American Society of Anesthesiologists status, distance of tumor from the anus, tumor size, reinforced anastomosis method, anastomotic reinforcing sutures and the implementation of prophylactic ileostomy. The outcome indicators include surgical safety (surgical time, intraoperative blood loss) and postoperative recovery (total hospital stay, first anal exhaust time, AL rate, anastomotic bleeding rate, anastomotic stricture rate, infection rate, intestinal obstruction rate, reoperation rate). For studies reporting medians with interquartile ranges, we applied established transformation methods to estimate means and standard deviations[17,18]. Technical variations in reinforcement methodologies, including interrupted sutures, continuous sutures, and barbed sutures. Suture materials primarily consisted of absorbable sutures, with some studies utilizing antimicrobial-coated variants. These variations were accounted for in subgroup analyses to assess their impact on outcomes.
Study quality
Dual investigators conducted blinded quality assessments using domain-specific instruments: Cochrane RoB 2.0 for RCTs and Newcastle-Ottawa Scale[19] for observational studies. Evidence synthesis stratified studies into three validity tiers: High (Newcastle-Ottawa Scale 7-9), moderate (4-6), and low methodological rigor (0-3). Inter-rater discrepancies underwent independent adjudication by a tertiary methodological expert.
Statistical analysis
Meta-analytic procedures were executed in RevMan 5.3 (Cochrane Collaboration, United Kingdom) employing a DerSimonian-Laird random-effects model[20]. Continuous measures were expressed as standardized mean differences (MD) with 95% confidence intervals (CI), while dichotomous outcomes were quantified through Mantel-Haenszel odds ratios (OR) and 95%CI. Heterogeneity assessment incorporated Cochran’s Q-test (χ2, P < 0.05) supplemented by I2 quantification, with I2 ≥ 50% defining substantial heterogeneity thresholds. Results visualization utilized forest plots with predictive intervals.
RESULTS
Literature search
The systematic search identified 1033 articles, with 208 duplicates removed. Title/abstract screening qualified 43 publications for full-text evaluation, of which 23 were excluded due to: Inaccessible raw datasets, data redundancy with included studies, and unobtainable full-texts. The final evidence synthesis incorporated 20 methodologically sound studies, with complete selection protocol detailed in Figure 1.
The twenty included articles comprised sixteen observational studies and four RCTs, encompassing 3726 participants[21-40]. Geographically, seventeen studies originated from China, two from Japan, and one from South Korea. The publication timeline spanned from August 2007 to March 2023, with study durations ranging from 14 to 76 months. Individual study sample sizes varied between 58 and 403 cases, cumulatively totaling 3726 patients undergoing laparoscopic anterior resection with double-stapled anastomosis for rectal malignancies located within 15 cm of the anal verge. Among the 20 studies, five used trans-anal reinforcing suture[21,32,37-39], fifteen studies employed intracorporeal laparoscopic reinforcing sutures[22-31,33-36,40]. Regarding the suture method, five studies used interrupted suture reinforcement[21-23,27,31], twelve studies used continuous suture reinforcement[24-26,28,30,32,34-37,39,40], and one study employed both suture reinforcement methods simultaneously[38]. Additionally, three studies implemented prophylactic ileostomy for individuals with preoperative or intraoperative risk factors[21,28,36]. Furthermore, six studies mentioned routine intraoperative air leakage tests to observe the adequacy of the anastomosis[21-25,27], and two studies also mentioned postoperative contrast enema radiography to help detect asymptomatic AL[23,25]. Seven studies reported the observation period for defining anastomotic leaks[21-23,27,28,31,32]. Supplementary Table 1 delineates key methodological attributes of included studies, with meta-analytic covariates systematically indexed in Table 1. The quality evaluations of the RCT and non-RCT articles are shown in Figure 2 and Table 2, respectively.
Figure 2 Quality assessment of the included articles according to the Cochrane risk of bias assessment tool.
A: Risk of bias graph; B: Risk of bias summary.
Table 1 The outcomes in the included studies, n (%).
AL: All twenty studies (3726 patients)[21-40] reported AL rates, with five studies specifying AL severity[24,25,31,36,38]. Pooled analysis demonstrated significantly lower AL incidence in the reinforced suture group vs controls (OR: 0.26, 95%CI: 0.19-0.35, P < 0.001, Figure 3A and Table 3).
Length of the operation: Operative time data from fifteen studies (2712 patients)[21,24-26,28-35,37-39] showed significant heterogeneity (I2 = 97%). The reinforced suture group required prolonged operative durations than non-reinforcing sutures group with significantly difference (MD: 15.25, 95%CI: 10.71-19.80, P < 0.001, Figure 3B).
Intraoperative blood loss: Fifteen studies (2712 patients)[21,24-26,28-35,37-39] reported blood loss measurements with substantial heterogeneity (I2 = 91%). No intergroup difference was observed (MD: 2.04, 95%CI: -2.35 to 6.42, P = 0.36, Figure 3C).
Length of hospital stay: Analysis of twelve studies (2259 patients)[21,24,26,28-31,33,34,37,38,40] revealed high heterogeneity (I2 = 95%). The reinforced group showed significantly shorter hospitalization (MD: -1.17, 95%CI: -1.78 to -0.57, P < 0.001, Figure 3D).
Anal exhaust time: Fourteen studies (2228 patients)[21,24,28-35,37-40] documented bowel function recovery, with marked heterogeneity (I2 = 91%). Earlier anal exhaust occurred in the reinforced group (MD: -0.13, 95%CI: -0.22 to -0.05, P = 0.002, Figure 3E).
Anastomotic bleeding: Five studies (763 patients)[26,32,33,37,38] reported bleeding rates without significant intergroup difference (OR: 0.41, 95%CI: 0.13-1.25, P = 0.12, Figure 3F).
Anastomotic stricture: The rate of anastomotic stricture was reported in three studies (508 patients)[25,32,36]. There was no significant difference between groups (OR: 0.65, 95%CI: 0.35-1.21, P = 0.17, Figure 3G).
Intestinal obstruction: Seven studies (1754 patients)[25,26,28-30,34,40] reported obstruction rates with low heterogeneity (I2 = 23%), showing no significant difference (OR: 0.91, 95%CI: 0.58-1.42, P = 0.68, Figure 3H).
Infection: Eight studies (1590 patients)[26,28-30,32,34,37,40] demonstrated lower infection rates in the reinforced group (OR: 0.54, 95%CI: 0.29-1.00, P = 0.05, Figure 3I).
Reoperation: The incidence of reoperation was reported in six studies (862 patients)[21,25,33,36-38]. The incidence of reoperation with the reinforced suture was significantly lower (OR: 0.19, 95%CI: 0.08-0.45, P = 0.0001, Figure 3J).
Subgroup analysis and sensitivity analysis
Subgroup analyses were conducted to investigate potential heterogeneity sources across studies (Tables 4, 5, 6, and 7). Stratification by study design, reinforcement methodology, reinforcing suture, and prophylactic ileostomy implementation revealed differential outcome patterns. For the primary endpoint, reinforced sutures significantly reduced AL incidence across all subgroups, including RCTs vs observational studies, interrupted vs continuous sutures, transanal vs transabdominal approaches, and low rectal cancer resections. The reduction in Grade C leakage severity reached particular significance (P = 0.001, Figure 4, Supplementary Figure 1). Regarding operative duration, heterogeneity appeared associated with reinforcing suture and ileostomy implementation. Interrupted suturing the “dog ears” area (P = 0.006) and the implementation of prophylactic ileostomy prolong the surgical duration (P = 0.008). Bowel function recovery analysis demonstrated earlier anal exhaust times with transanal reinforcement vs laparoscopic approaches (P < 0.001) and in ileostomy cases vs non-ileostomy controls (P = 0.05). Sensitivity analyses were performed by sequentially excluding individual studies from each outcome assessment. These sequential exclusions demonstrated no significant alterations in the pooled results, confirming the relative stability of the findings.
Figure 5 Funnel plot for publication bias basing on anastomotic leakage in included studies.
OR: Odds ratio.
DISCUSSION
The International Study Group of Rectal Cancer consensus guidelines established a clinically validated three-grade classification system (A, B, and C) in 2010 to standardize the diagnosis of AL following rectal anterior resection. This system defines AL as transmural defects at colorectal/coloanal anastomotic sites that establish pathological continuity between the intestinal lumen and extraintestinal spaces. Within this framework, grade A leakage (radiologically confirmed) requires no therapeutic intervention, grade B (clinically significant) necessitates non-surgical management, while grade C (life-threatening) mandates urgent reoperation. AL pathogenesis involves multifactorial interactions, with key determinants spanning anatomical, physiological, and clinical domains. Critical risk factors include the distance of the anastomotic site from the anal margin, intestinal cavity pressure, anastomotic tension, local blood supply, operation time, tumor staging, body mass index, age, gender, preoperative adjuvant radiotherapy and chemotherapy, nutrition status, hypoalbuminemia, intraoperative blood loss, etc[10-12].
Reinforcement of the anastomotic suture line remains an essential technical consideration in colorectal surgery. This procedure typically involves applying additional sutures transanally or intracorporeally along the staple line, either completely or partially encircling it with interrupted/continuous stitches. This technique specifically targets the “dog ears” area - the anatomical junction where the linear rectal transection meets the circular sigmoid-rectal end-to-end anastomosis. Strategically placed reinforcing sutures have been demonstrated to effectively decrease anastomotic tension, improve regional perfusion, strengthen vulnerable tissue areas, and close any incipient gaps at the anastomotic site, as evidenced by studies[41,42].
The principal finding of our meta-analysis demonstrates a statistically significant reduction in AL incidence with reinforcement sutures compared to conventional techniques (3.16% vs 11.16%, P < 0.001). Given methodological heterogeneity across studies - including variations in design (RCTs vs observational), reinforcement approaches (interrupted/continuous), surgical access (transanal/intracorporeal), and tumor localization - we performed comprehensive subgroup analyses. These analyses consistently revealed AL risk reduction across all subgroups (Supplementary Figure 1), with particular significance in Grade C leakage mitigation (P = 0.001), corroborated by reduced reoperation rates (1.16% vs 7.17%, P < 0.001). Notably, two transanal reinforcement studies showed nonsignificant AL rate differences. Nonetheless, Baek et al[21] suggests that trans-anal suture reinforcement may reduce the necessity for a diverting ileostomy. Moreover, Liu et al’s research[38], despite not showing a statistically significant variance, demonstrated a tendency towards a lower incidence of AL (4.65% in the trans-anal suture group vs 16.67% in the control group) and a reduced occurrence of grade C AL (one case in the transanal suture group compared to three in the control group), indicating a potential clinical benefit of this approach.
Postoperative hemorrhage predominantly manifests within 24-48 hours following rectal cancer resection, with anastomotic sites representing the most frequent bleeding origin. The use of double stapler anastomosis may encounter several pitfalls: (1) Inadequate closure of blood vessels due to thick tissue or improper selection of stapler height; (2) Accidental displacement during the manual stapling process, resulting in stapling defects; (3) Insufficient staple numbers or the presence of quality defects in some staplers, leading to improper closure of small arteries; and (4) AL or SSI corrodes the arteries. Existing evidence suggests that relying solely on instrument suturing may lead to incomplete suturing during anastomosis, resulting in ineffective nailing of the mucosal layer and an increased risk of anastomotic bleeding. However, in the case of fully reinforced anastomoses, the probability of bleeding may be reduced[43]. Although the current meta-analysis did not demonstrate a significant advantage in reducing anastomotic bleeding with reinforced sutures, the likelihood of bleeding was indeed lower (reinforced group 3/198, control group 10/205).
The primary concerns following reinforced suturing encompass potential impacts on gastrointestinal functional recovery, anastomotic stenosis, and intestinal obstruction. Regarding anastomotic stenosis, cases in the reinforced group may result from luminal narrowing following full-thickness reinforcement, whereas in the non-reinforced group, stenosis may develop secondary to AL, potentially due to localized tissue edema and proliferative changes post-leakage. Our research indicates that reinforced suturing has no discernible effect on this. Contemporary practice predominantly utilizes absorbable sutures with low tissue reactivity, including antimicrobial properties, which minimize inflammatory responses and excessive scar formation. With proficiency in surgical techniques, even in continuous suturing, appropriate suture tension prevents anastomotic stenosis. At the same time, some studies have only sutured the high-risk “dog ear” region, further mitigating iatrogenic stenosis[23,24,33,34]. Current evidence suggests most strictures arise secondarily from leakage-induced inflammatory cascades and granulation tissue hyperplasia[44-46]. Thus, reinforcement sutures may theoretically prevent stricture formation through leakage reduction. Liu et al[37] observed well-healed anastomotic sites without granulation tissue on six-month postoperative colonoscopy. Significantly, Zhang et al[32] reported seven anastomotic strictures caused by trans-anal running full-layer stitches around the entire circular anastomosis with absorbable sutures. Therefore, appropriate suture methods and tension control during full-thickness closure may mitigate stenosis risk. However, at present, there is no consensus on the method of anastomotic reinforcement.
Subgroup analyses identified interrupted suture patterns and prophylactic ileostomy implementation as primary sources of heterogeneity. Given the comparable AL prevention efficacy between techniques, patients undergoing continuous closure may derive greater clinical utility from reduced operative duration. Bowel function recovery analysis revealed significantly earlier time to first flatus with transanal reinforcement vs laparoscopic approaches (MD: -0.73, 95%CI: -1.12 to -0.34). This discrepancy could potentially stem from multifactorial determinants including tumor localization, variations in bowel pre-operative preparation, and time to get out of bed after surgery. Additional heterogeneity contributors encompassed baseline characteristics and intraoperative variables. Current evidence remains insufficiently robust to establish definitive recommendations, necessitating prospective trials controlling for these confounding factors.
Our findings demonstrate that anastomotic reinforcement confers significant protective effects irrespective of surgical approach (trans-anal vs. intracorporeal) or suture technique (interrupted vs. continuous). Current reinforcement methodologies encompass: (1) Trans-anal or intracorporeal access; (2) Interrupted or continuous suturing patterns; and (3) Segmental reinforcement of high-risk “dog-ears” regions vs circumferential reinforcement. Suture material selection primarily involves conventional absorbable sutures (applicable to both techniques) and barbed suture devices (exclusively for continuous closure). Transanal reinforcement proves particularly advantageous in low/ultralow rectal cancer patients with challenging pelvic anatomy (obesity or narrow pelvis). This approach facilitates direct visualization and closure of residual dog-ear defects while enabling concurrent ostomy creation without prolonging operative duration[47]. Additionally, the laparoscopic pneumoperitoneum pressure can detect potential AL during suturing. Modern surgery retractors have enhanced the safety and precision of trans-anal techniques, though inherent risks persist: The distal rectal wall’s anatomical vulnerability, characterized by thin muscular layers and absence of serosal support, creates inherent technical challenges. If the rectum and anus are overstretched during trans-anal sutures, the rectal wall may be injured with stitches, firstly piercing mucosa, and anastomotic stoma can rupture. This complication occurs most frequently during anterior wall reinforcement with continuous suturing techniques, as their uninterrupted suture lines cannot circumvent high-risk regions, whereas interrupted sutures enable precise avoidance[48]. The intracorporeal suture is feasible for an anastomotic site with a high position. In combination with our-self experience, accompanied by the advancements of laparoscopic instruments and operative techniques, the distance from the anastomotic site to the anal verge is no longer the sole determinant. In patients with low body mass index or spacious pelvic anatomy, intracorporeal suturing can be safely implemented even for anastomotic sites located 1-5 cm from the anal verge[49-51].
Existing evidence predominantly supports targeted reinforcement of “dog ear” regions through selective suturing[23,24,33,34]. Our operative findings suggest enhanced safety and efficacy when resecting one of the two corners made by crossing the circular and linear staple lines and strengthening another corner in the meantime. Another critical consideration is that selecting the most appropriate reinforcement methods and surgical approaches is imperative, absolutely avoiding injuries caused by sutures. In most cases, targeted reinforcement of “dog ear” regions or anatomically vulnerable zones proves sufficient. Diverting ileostomy should be implemented without hesitation when encountering insufficient quality of anastomosis, positive leak test, excessive anastomotic tension, or inadequate vascular perfusion.
Regarding postoperative outcomes, the results of the current meta-analysis indicated that the operating time for reinforced anastomosis was significantly prolonged compared to conventional techniques, primarily attributable to the additional suturing steps. Although this temporal increase reached statistical significance, its clinical relevance appeared negligible, as no associations were observed with elevated anesthesia-related complications or other perioperative adverse events. Subgroup analyses further demonstrated that prolonged operative duration was predominantly driven by interrupted suture reinforcement (P = 0.006), whereas continuous barbed suture techniques showed comparable operative times to conventional methods, aligning with existing clinical evidence. Early anal exhaust time and reduced length of hospital stay are considered as advantages of suture reinforcement.
Existing evidence demonstrates that intervention with anastomotic reinforcement sutures can effectively reduce postoperative complications[21]. The reinforced suture group exhibited earlier independent mobility, faster intestinal function recovery, and shorter hospital stays. Yi et al[28] demonstrated a 16.5% reduction in AL incidence correlating with accelerated perioperative recovery in reinforced anastomosis patients, translating to significantly decreased mean hospitalization duration (11.52 days vs 13.79 days, P = 0.035). It is logical to recognize that patients experiencing earlier return of bowel function and lower AL rates would require shorter hospitalization, findings that align with our pooled meta-analytic results. No statistically significant difference emerged in intraoperative blood loss between the techniques. Since all patients included in the studies received treatment at a high-capacity tertiary surgical center, where surgeons with skilled surgical operation and deep anatomical knowledge reserve can be effective in bleeding control during suturing.
SSIs rates in colorectal surgery remain high, ranging from 15% to 30% in some studies[52-55]. These infections impose substantial healthcare costs and prolong hospitalization duration[56]. Reoperation rates could be reduced through effective mitigation of SSI risk. AL facilitates peritoneal contamination through luminal content extravasation, precipitating organ/space infections and systemic inflammatory responses. Emergency reoperation following AL paradoxically heighten infectious morbidity risks. Reinforcement sutures effectively safeguard anastomotic integrity, thereby reducing both SSI occurrence and reoperation necessitated by leakage events. Our findings demonstrate that reinforced anastomotic sutures can effectively diminish leakage-associated secondary infections (OR: 0.54, 95%CI: 0.29-1.00, P = 0.05). Concurrently, due to the reduced incidence of AL, the reinforced suture achieved a lower reoperation rate, which is logically sound, as one of the most common reasons for reoperation after rectal surgery is the management of AL and its associated complications. The reoperation rate naturally reducibility through mitigation of AL occurrence, particularly symptomatic leaks (Grade C leaks). Ban et al’s research[25] confirms this hypothesis, wherein reinforced suturing predominantly attenuated Grade C leak incidence, results corroborated by our subgroup analysis (P = 0.001). With reduced reoperations and postoperative infections, patient recovery becomes more accessible with concurrent shortening of hospitalization duration. In summary, reinforced sutures could effectively reduce postoperative complications.
Our meta-analysis presents distinct advantages compared to existing published analyses. Firstly, our study incorporates an expanded dataset. Specifically, we included one RCT and eight retrospective cohort studies, which were not encompassed in prior systematic reviews. Second, our meta- analysis further performed subgroup analyzes based on study type (RCT or retrospective study), reinforced suture method (transabdominal or transanal), low rectal cancer (within 5-6 cm from the anal verge), etc., which also makes our conclusions more objective. Finally, our study compares reoperation rates between groups and shows that reinforced sutures can help reduce reoperation rates, a finding not covered in previous meta-analyses. While acknowledging these strengths, the synthesized findings require cautious interpretation due to methodological constraints. The systematic search identified 20 qualifying investigations, comprising 4 RCTs and 16 retrospective observational studies. The predominance of observational study designs may introduce selection bias, resulting in a relatively low level of clinical evidence. Second, variations in reinforcement suturing types, suturing methodologies, and tumor location across studies may contribute to heterogeneity and influence outcomes. Third, the absence of longitudinal functional outcome data and cost-effectiveness analyses constrains the generalizability of our conclusions. Future investigations should integrate cost-benefit evaluations to assess reinforced sutures’ economic implications. Finally, as all studies originated from East Asia populations, so it might not completely reveal the effect of reinforcing sutures outside Asia.
CONCLUSION
Our study demonstrates that properly implemented reinforced suturing represents a potentially cost-effective preventive strategy against AL in rectal cancer procedures. Nevertheless, current evidence limitations and interstudy heterogeneity necessitate cautious interpretation of these results. More well-designed large-sample RCTs are needed to assess the efficiency and clarify the indications of reinforced sutures in future research.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A, Grade A, Grade A, Grade B
Novelty: Grade A, Grade A, Grade B, Grade D
Creativity or Innovation: Grade A, Grade A, Grade A, Grade B
Scientific Significance: Grade A, Grade A, Grade A, Grade B
P-Reviewer: Dimofte GM; Zhang A S-Editor: Wei YF L-Editor: A P-Editor: Xu ZH
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