Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate

Multiple robotic stapler firings to transect the rectum are not associated with anastomotic leakage

AIM

The relationship between the number of stapler firings (SFs) during robotic rectal transection and the risk of colorectal/coloanal anastomotic leakage (AL) is controversial. This study investigates whether the number of robotic SFs is associated with an increased risk of AL.

METHOD

Retrospective review of adult patients who underwent robotic total mesorectal excision (TME) and partial mesorectal excision (PME) with double-stapled colorectal or coloanal anastomosis for both benign and malignant colorectal diseases between 2015 and 2023 across three enterprise-wide hospitals.

PRIMARY OUTCOME

the effect of multiple SFs on postoperative AL rate among patients who underwent one, two, or three or more SFs.

SECONDARY OUTCOME

the effects of other potential risk factors on postoperative AL.

RESULTS

Of 503 patients who underwent robotic colorectal resection with a double-stapled anastomosis, 56 (11%) developed a postoperative AL. The number of SFs was not associated with the AL rate (p = 0.51): the univariable and multivariate analyses found no correlation between the AL rate and the increasing number of SFs required, compared with one SF as the reference (adjusted two SFs, OR = 1.1, 95% CI: 0.6-2.2, p = 0.77 vs. adjusted three or more SFs, OR = 0.98, 95% CI: 0.4-2.3, p = 0.96). On multivariate analysis, AL was strongly associated with male gender (OR = 2.5, 95% CI: 1.3-4.9, p = 0.005) and with TME versus PME (OR = 2.8, 95% CI: 1.5-5.5, p = 0.002).

CONCLUSION

The number of robotic SFs for rectal transection is not correlated with postoperative AL.

Fact or fiction? Does the position of the end-to-end (EEA) stapler spike matter for colorectal anastomoses using a double-stapled technique?

AIM

Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end-to-end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity.

METHOD

This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left-sided colon resection with double-stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak.

RESULTS

Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end-colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05-0.87, p = 0.03).

CONCLUSIONS

For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks.

Early and late clinico-pathologic outcomes of minimally invasive total mesorectal excision for rectal cancer: A propensity score-matched comparison of robotic and laparoscopic approaches

BACKGROUND

This study aimed to compare the early and late clinical outcomes of laparoscopic and robotic total mesorectal excision (TME) using propensity score matching.

METHODS

The retrospective study included 489 patients who underwent laparoscopic or robotic TME for rectal cancer between June 2011 and December 2018. Overall, 131 matched pairs were generated via propensity scoring matching according to several factors.

RESULTS

The matched groups had generally similar demographic characteristics. The robotic TME group had significantly longer mean times for the total operation and the TME procedure. There were no significant differences in terms of the other procedure-specific parameters, although the robotic TME group had significantly shorter duration of hospitalisation and shorter duration of need for postoperative indwelling urinary catheter. Moreover, the robotic TME group had non-significantly lower rates of late postoperative complications and reoperation.

CONCLUSIONS

Early and late clinico-pathologic outcomes of robotic TME were comparable to that of laparoscopic TME.