Comparative Efficacy of Reinforced Suturing, Transanal Drainage Tube, and No Additional Intervention in Preventing Anastomotic Leakage after Rectal Cancer Surgery: A Network Meta-Analysis

Background Anastomotic leakage (AL) is a severe complication after rectal cancer surgery. This network meta-analysis (NMA) compares reinforced suturing (RS), transanal drainage tube (TDT), and no additional intervention (NRT) for AL prevention. Methods A Bayesian NMA was conducted according to PRISMA-NMA guidelines. PubMed, Web of Science, and Embase were searched for randomized controlled trials and observational studies comparing RS, TDT, or NRT in adults undergoing anterior resection for rectal cancer, with AL as the primary outcome. Secondary outcomes included Grade C AL, stricture, bleeding, ileus, and wound infection. Results 16 studies (3 RCTs, 11 RNCTs, and 2 PNCTs; n = 4562) were included. For overall AL incidence, both RS (OR 0.32, 95% CrI 0.16–0.62) and TDT (OR 0.47, 95% CrI 0.33–0.63) significantly reduced AL vs. NRT. RS ranked highest (SUCRA 0.93), though no significant difference was observed between RS and TDT (OR 1.44, 95% CrI 0.68–3.09). For Grade C AL, RS significantly reduced risk versus both TDT (OR 5.01, 95% CrI 1.33–28.67) and NRT (OR 0.10, 95% CrI 0.02–0.32; SUCRA 0.99). No significant differences were found among interventions for anastomotic bleeding, ileus, or wound infection. TDT showed a trend toward reduced anastomotic stricture risk (SUCRA 0.73), but the effect was not statistically significant (TDT vs. NRT: OR 0.68, 95% CrI 0.19–2.27). Sensitivity analysis restricted to larger studies (≥ 100 patients/group) confirmed the robustness of primary outcomes. Conclusions Both RS and TDT reduce overall AL risk compared to NRT. RS demonstrates a significant and clinically important advantage over TDT in preventing catastrophic Grade C AL, supporting its prioritization for high-risk patients.