Preliminary evaluation of two-row versus three-row circular staplers for colorectal anastomosis after rectal resection: a single-center retrospective analysis

Abstract

Circular staplers for colorectal anastomoses signi cantly ameliorated post-operative outcomes after rectal resection. The more recent three row technology was conceived to improve anastomotic resistance and, thus, lower the incidence of anastomotic complications. The aim of this study was to evaluate potential advantages of three row circular staplers(Three-CS) on anastomotic leakage(AL), stenosis(AS) and hemorrhage(AH) rates after rectal resection as compared to two row circular staplers(Two-CS). MethodsAll rectal resections for rectal cancer between 2016 and 2021 were retrospectively included. Patients were classi ed according to the circular stapler employed in Two-CS and Three-CS cohorts. AL, AS and AH rates were compared between the two populations. Additionally, the prognostic role of the type of circular stapler on AL onset was evaluated. ResultsThree-hundred and seventy-ve patients underwent a rectal resection with an end-to-end anastomosis during the study period:197 constituted the Two-CS group and 178 the Three-CS cohort. AL rate was 6.7%, signi cantly higher in the Two-CS group(19-9.6%) as compared to the Three-CS cohort(6-3.4%) (p=0.01). No difference was noted in terms of AL severity. Although not statistically signi cant, a lower incidence rate of AL was evidenced even in the subset of patients with low rectal cancers(4.5%vs12.5% in the Two-row cohort;p=0.33). At the multivariate analysis, Two-CSs was a negative prognostic factor for AL onset(OR: 2.63;p=0.03). No difference was noted between the two groups in terms of AS and AH. ConclusionThree-row CSs signi cantly decrease the rate of AL after rectal resection. Further multicenter controlled trials are still needed to con rm the advantages of Three-row CSs on anastomotic complications.

Two-row, three-row or powered circular stapler, which to choose when performing colorectal anastomosis? A systematic review and meta-analysis

“…The decrease in the incidence of anastomotic leakage reported by some publications on the experience of the new PCS [ 13 , 19 , 25 , 27 , 37 ] and TRCS [ 12 , 29 , 38 ] compared with the two-row circular staplers should be viewed with caution because they are observational studies, not randomized clinical trials. Furthermore, there is some heterogeneity in the studies because multicentre studies have been included, some of them with cases from large national databases or on-going clinical trials not designed to assess the difference in leakage rates among different devices [ 29 , 39 , 40 ].…”

“…Sensitivity analysis did not detect significant problems in the PCS meta-analysis. However, in the case of TRCS, the work presented by Wang et al [ 30 ] was the one that introduced the greatest heterogeneity to the analysis, probably because sample size and the values recorded for leakage differed from those provided by the other three studies [ 12 , 28 , 29 ].…”

“…One of the limitations of this meta-analysis is the small number of studies available and the absence of randomised clinical trials. All the studies included in the meta-analyses, except Quero et al and Want et al studies [ 30 , 38 ], have included propensity score matching, with the inherent limitations of this statistical method. The validity and reality of results of two of the included studies [ 37 , 39 ] has been questioned by other authors who appreciated possible caveats in the propensity score matching [ 29 ], although they did not question the results of other studies with similar characteristics [ 12 ].…”

Efficacy of reinforcing sutures for prevention of anastomotic leakage after low anterior resection for rectal cancer: A systematic review and meta‐analysis

“…2,3 Anastomotic leakage not only decreases the patients' quality of life, 4 but also negatively affects their survival. 5,6 Several methods are used for preventing anastomotic leakage after low anterior resection in patients with rectal cancer, such as defunctioning loop ileostomy, 7 three-row circular staplers, 8 low inferior mesenteric artery (IMA) ligation, 9 and transanal drainage tube use. 10 All of these methods have problems of one kind or another, such as defunctioning loop ileostomy requiring secondary surgery, patients with transanal drainage tube placement experience perianal pain.…”

Risk of anastomotic leakage with two-row versus three-row manual circular staplers in colorectal anastomosis: a U.S. cohort study

“…In another single-center head-to-head circular stapler comparison, Quero et al [ 10 ] reported a lower overall AL risk after 375 rectal cancer resections in the Medtronic EEA ™ circular stapler with Tri-Staple ™ technology group (6/178, 3.4%) than the two-row stapler group (unspecified combination of Medtronic EEA ™ circular stapler with DST ™ Series technology and Ethicon ™ circular stapler, 19/197, 9.6%) ( p = 0.01). However, the risk of ISREC grade C AL [ 19 ], a severe form of AL leading to re-operation, did not differ between the two groups (2.5% in the two-row vs. 2.2% in the three-row circular stapler group).…”