The use of single-stapling techniques reduces anastomotic complications in minimal-invasive rectal surgery

Laparoscopic Resection and Anastomosis in Bowel Endometriosis: Single Stapler Surgical Technique

Background and Objectives

Endometriosis affects 10% of reproductive-age women globally, with bowel endometriosis in 3.8%-37% of cases, primarily involving the rectum and sigmoid. Surgical excision is the gold-standard treatment for deep infiltrating endometriosis (DIE). Our objective was to evaluate the feasibility, safety, and efficacy of a single-stapler laparoscopic resection and anastomosis technique for bowel DIE.

Methods

This retrospective study analyzed 17 cases managed from January 2023 to June 2024. Clinical presentation, surgical outcomes, and follow-up data were reviewed. Symptom improvement and complications were assessed during a minimum 3-month postoperative period.

Results

Patients primarily presented with preoperative symptoms, including progressive dysmenorrhea, dyspareunia, and dyschezia. All anastomoses were tension-free with negative margins; no diversion stomas were needed. Postoperative recovery was smooth, with significant symptom relief and no complications.

Conclusion

The single-stapler technique for laparoscopic rectosigmoid resection is a safe, effective approach for bowel DIE, offering excellent outcomes with significant symptom relief and minimal severe complications.

Circular staplers and anastomotic leakage in colorectal surgery: meta-analysis

BACKGROUND

Anastomotic leakage is a feared complication after colorectal resection. Recent advancements in surgical techniques, particularly the use of circular staplers, have aimed to improve postoperative outcomes. However, the optimal choice of circular stapler remains uncertain, with debate surrounding its impact on anastomotic leakage rates. The aim of this meta-analysis was to evaluate the impact of different circular stapler characteristics on anastomotic leakage occurrence after left colorectal resection.

METHODS

A systematic review and meta-analysis using PubMed, Scopus, and Web of Science databases to identify studies on the correlation between circular staplers and anastomotic leakage occurrence were performed up to November 2023 (PROSPERO registration: CRD42024519036). The literature search was conducted according to the PRISMA guidelines and performed using the following search terms: 'colorectal surgery', 'staplers', 'complications'. Only retrospective, cohort, prospective and randomized clinical trials on anastomotic leakage rate after left colorectal resection, including adult patients (over 18 years of age) and published in English were included. Exclusion criteria were articles with different designs, and studies including extra-colonic or right/transverse colon diseases. The quality assessment of the study was performed using the Newcastle-Ottawa classification. The outcome of interest was the analysis of each staplers' characteristics including: diameter, number of rows, technology (manual versus powered) and anastomotic technique (single- versus double-stapling technique) on anastomotic leakage occurrence.

RESULTS

Twenty-one retrospective studies were selected including 24 511 patients. A higher anastomotic leakage rate was documented for 31/33 mm stapler diameters compared with the 28/29 mm (OR -0.92, 95% c.i. -1.74 to -0.10; P = 0.02), while no significant difference was found between the 25 mm and 28/29 mm diameters (OR -0.46, 95% c.i. -1.39 to 0.46; P = 0.2). Similar anastomotic leakage rates were found for the two- and three-row circular stapler groups (OR -0.01, 95% c.i. -0.16 to 0.13; P = 0.85). Conversely, the powered technology related to a significantly lower rate of anastomotic leakage compared with the manual technology (OR -0.83, 95% c.i. -1.13 to -0.35; P < 0.001). Similarly, the single-stapling technique related to a lower rate of anastomotic leakage compared with the double-stapling technique (OR 0.79, 95% c.i. 0.33 to 1.25; P < 0.001).

CONCLUSION

This study shows a higher anastomotic leakage rate for larger circular staplers and manual technology. Similarly, the single-stapling technique has advantages over the double-stapling technique, while the tri-staple technology does not appear to confer advantages on anastomotic leakage occurrence.

Systemic assessment of manual circular stapler versus powered circular stapler for anastomosis in rectal cancer: a large-scale Chinese multicenter prospective cohort study

Mechanical anastomosis in rectal cancer surgery offers several advantages but is plagued by complications like leaks and strictures. Variations in surgeons' experiences affect outcomes, but powered circular anastomosis has emerged as a promising solution, ensuring uniform staple formation, and reducing manual manipulation. This multicenter, randomized, parallel-controlled study in China compared IntoCare's powered circular staplers (ICS) with manual circular staplers (MCS) in 382 patients (195 ICS, 187 MCS). Both groups had comparable anastomotic leakage rates. ICS significantly reduced anastomosis time while maintaining similar safety profiles. Postoperative recovery and complication rates were closely matched. The use of ICS in rectal cancer surgeries effectively reduces anastomosis time without compromising safety, offering a promising innovation to enhance the efficacy of rectal cancer surgeries while maintaining patient safety.

The bow tie technique for single stapled colorectal anastomosis: technical note

AIM

In this technical note we describe a simplified totally transabdominal technique to perform a single stapled end-to-end colorectal anastomosis without the need for transanal transection, linear stapler line resection, purse string or dog-ear suturing.

METHOD

The rationale and the technique itself are first explained by using a schematic design. Next, step-by-step pictures of one of our cases show the feasibility and advantages of this technique. At the end, the limits of this technique are illustrated.

RESULTS

The technique was used for 20 colorectal anastomosis, 9 benign and 11 oncological cases. Median age was 68 years and average BMI was 28 kg/m2. Risk factors for anastomotic leakage were reported in 10 cases. The bow tie technique was performed in every case and the linear stapler line was entirely resected in all cases. No positive air leak test or anastomotic leakage was reported.

CONCLUSIONS

The bow tie technique is a feasible technique to perform an end-to-end single stapled colorectal anastomosis with promising results on anastomotic leakage. Further research with larger prospective data collection is necessary to validate this technique and show its potential benefit on anastomotic leakage.

The Effect of Multifaceted Anastomotic Leakage Prevention via ICG and SST for Lower Rectal Anastomosis

BACKGROUND/AIM

In rectal cancer surgery, anastomotic leakage (AL) is the most important complication and has a reported frequency of 11-15%. The causes of AL leakage are complex, and AL prevention should be performed in multiple directions. Thus, this study examined the usefulness of the comprehensive and multifaceted AL preventive measures.

PATIENTS AND METHODS

In total, 164 rectal surgery patients who had low rectal staple anastomosis below the peritoneal reflection were enrolled. The patients were divided into two groups: (i) the multifaceted AL prevention group (MP group, n=34) and (ii) the insufficient AL prevention group (IP group, n=130). Multifaceted AL prevention was defined as intestinal blood flow evaluated via indocyanine green (ICG)-fluorescence imaging (FI), the use of a single-staple technique (SST) without intersecting stapling lines or "dog ears", the use of transanal suture reinforcement according to the air leakage test, and the use of a transanal tube for anatomical decompression and a diverting stoma for diverting the fecal stream. The AL rates were retrospectively compared between the two groups. The data are expressed as the median and interquartile range.

RESULTS

The rate of AL was significantly lower in the MP group (0%) than in the IP group (11.54%) (p=0.0423).

CONCLUSION

Multifaceted AL prevention, including ICG-FI and SST, achieved a zero incidence of AL. Multifaceted prevention significantly lessened AL more than inadequate prevention did. Therefore, if the weight of each preventive measure cannot be clearly identified, to avoid AL, it is important to take all preventive measures from multiple aspects.

Association Between Cross-Stapling Technique in Mechanical Colorectal Anastomosis and Short-term Outcomes

BACKGROUND

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered possible risk factors for anastomotic leakage.

OBJECTIVE

This study aimed to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis after minimally invasive surgery.

DATA SOURCES

A systematic review of the published literature was undertaken. PubMed/MEDLINE, Web of Science, and Embase databases were screened up to July 2023.

STUDY SELECTION

Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction compared with the conventional method of double-stapled anastomosis were included.

INTERVENTIONS

Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared.

MAIN OUTCOME MEASURES

The rate of anastomotic leak was the primary end point of interest. Perioperative details including postoperative morbidity were also appraised.

RESULTS

There were 2537 patients from 12 studies included for data extraction, with no significant differences in age, BMI, or proportion of high ASA score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure than for the conventional procedure (OR = 0.38 [95% CI, 0.26-0.56]). The incidences of overall postoperative morbidity (OR = 0.57 [95% CI, 0.45-0.73]) and major morbidity (OR = 0.48 [95% CI, 0.32-0.72]) following modified stapled anastomosis were significantly lower than following conventional double-stapled anastomosis.

LIMITATIONS

The retrospective nature of most included studies is a main limitation, essentially because of the lack of randomization and the risk of selection and detection bias.

CONCLUSIONS

The available evidence supports the modification of the conventional double-stapled technique with the elimination of 1 of both dog-ears as it is associated with a lower incidence of anastomotic-related morbidity.

The Colorectal Anastomosis: A Timeless Challenge

Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.