Economic Analysis of Leak Complications in Anastomoses Performed with Powered versus Manual Circular Staplers in Left-Sided Colorectal Resections: A US-Based Cost Analysis

Current evidence on powered versus manual circular staplers in colorectal surgery: a systematic review and meta-analysis

PURPOSE

This meta-analysis aims to evaluate the efficacy of powered circular staplers (PCS) compared to manual circular staplers (MCS) in reducing anastomotic leakage (AL) and postoperative bleeding (AB) in colorectal surgery.

METHODS

Extensive searches were performed in the Embase, PubMed, and SCOPUS electronic bibliographic databases. Most studies were of an observational nature, and only one randomized clinical trial was identified.

RESULTS

Twelve studies met the inclusion criteria for anastomotic leakage and five for anastomotic hemorrhage. The number of patients included for AL analysis was 4524. The leakage rate was 4.6% (208 cases). The number of patients with AB was 2868 with a bleeding rate of 4.99% (143 patients). After identifying outliers and studies with possible selection bias, the odds ratio (OR) for leaks and PCS was 0.38 (95% CI 0.26-0.55), the relative risk was - 0.05 (95% CI - 0.07 to 0.03), and the number needed to treat to prevent one leak was 20. For bleeding, the PCS OR for PCS was 0.20 (95% CI 0.0772-0.5177).

CONCLUSION

Powered circular staplers could be associated with a significantly lower risk of leakage and anastomotic bleeding than two-row manual circular staplers. Further prospective randomized trials are needed to validate these findings.

Anastomotic leak rate following the implementation of a powered circular stapler in elective colorectal surgeries: a retrospective cohort study

BACKGROUND

The objective of this study was to compare the anastomotic leak rates between powered and manual circular staplers in elective left-sided colorectal resections.

METHODS

A retrospective cohort study of elective left-sided colorectal resections before and after implementation of a powered circular stapler at a tertiary care center was conducted. The manual stapler group consisted of consecutive resections performed between January 2016 to December 2016 and the powered stapler group, between September 2021 and December 2022. Primary outcome was 30-day anastomotic leak rate. A chi-squared analysis was performed to compare anastomotic leak rates. Factors associated with anastomotic leak were examined.

RESULTS

Two-hundred forty-seven patients were included: 154 in the manual stapler group and 93 in the powered stapler group. Mean (SD) age was 60 (15) years old, 37.7% were female and 72.9% of resections were performed for malignancy. Both groups had similar patient characteristics and surgical technique. Overall leak rate was 2.0% in the manual stapler group and 10.8% in the powered stapler group. The powered staplers were found to have 6.06 times the odds of leak compared to manual staplers (95% CI, 1.62-22.65; p = 0.01). None of the other factors were found to be associated with anastomotic leak.

CONCLUSIONS

Patients who had left-sided colorectal anastomosis had higher anastomotic leak rates with powered compared to manual circular staplers. This finding is contrary to previous retrospective studies that found lower leak rates with powered staplers.

Effect of powered circular stapler in colorectal anastomosis after left-sided colic resection: systematic review and meta-analysis

PURPOSE

Anastomotic leak (AL) remains the most important complication after left-sided colic anastomoses and technical complications during anastomotic construction are responsible of higher leakage incidence. Powered circular stapler (PCS) in colorectal surgery has been introduced in order to reduce technical errors and post-operative complications due to the manual circular stapler (MCS).

METHODS

A systematic review and meta-analysis were performed. An electronic systematic search was performed using Web of Science, PubMed, and Embase of studies comparing PCS and MCS. The incidence of AL, anastomotic bleeding (AB), conversion, and reoperation were assessed. PROSPERO Registration Number: CRD42024512644.

RESULTS

Five observational studies were eligible for inclusion reporting on 2379 patients. The estimated pooled Risk Ratios for AL and AB rates following PCS were significantly lower than those observed with MCS (0.44 and 0.23, respectively; both with p < 0.01). Conversion and reoperation rate did not show any significant difference: 0.41 (95% CI 0.09-1.88; p = 0.25) and 0.78 (95% CI 0.33-1.84; p = 0.57); respectively.

CONCLUSION

The use of PCS demonstrates a lower incidence of AL and AB compared to MCS but does not exhibit a discernible influence on reintervention or conversion rates. The call for future randomized clinical trials aims to definitively clarify these issues and contribute to further advancements in refining surgical strategies for left-sided colonic resection.

Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis

BACKGROUND

Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective.

METHOD

This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed.

RESULTS

A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was - €74,915.28 per patient without anastomotic complications.

CONCLUSION

The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.

Defining digital surgery: a SAGES white paper

BACKGROUND

Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas.

METHODS

This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology.

RESULTS

In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth.

CONCLUSION

Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

Short-term outcomes associated with the use of a new powered circular stapler for rectal reconstructions: a retrospective study comparing it to manual circular staplers using inverse probability of treatment weight analysis

BACKGROUND

The most common postoperative complication in malignant rectal surgery is anastomotic leakage (AL). AL after anterior or low anterior resection in rectal tumors is a fatal postoperative complication. Recently, the first automated suture circular stapler, which is expected to reduce the incidence of AL, (J&J). MATERIALS AND METHODS: This study included a total of 248 rectal tumor patients who underwent double stapler technique (DST) anastomotic procedures in the department of gastroenterological surgery /pediatric surgery at Gifu University School of Medicine from January 2017 to December 2021. The experience of a single institution utilizing the The Echelon circular™ stapler (ECP stapler:Manual VS Automatic) in rectal surgery cases was evaluated retrospectively from maintained database.

RESULT

One hundred thirty-nine patients (58.4%) were performed by manual circular stapling, 99 patients (41.6%) by powerd circular stapling. Diverting stoma was performed in 45 cases (32.4%) by manual circular stapling, 42 patients (42.4%) by powerd circular stapling Postoperative complications were occurred clavien-dindo grade II or higher in 57 cases (23.9%) and grade III or higher in 20 cases (8.4%). Anastomotic leakage occurred in 14 patients (5.9%) within all grades. After IPTW, the variables of patient characteristics was SMD ≤ 0.2 (Table.3), and there was a significant difference in anastomotic leakage (Odds Ratio (OR), 0.57; 95% Confidence Interval(CI), 0.34-0.98; p = 0.041). In addition, there was no significant difference in postoperative complications in grade II or higher (OR, 0.88; 95%CI, 0.65-1.19; p = 0.417) and grade III or higher (OR, 0.46; 95%CI, 0.29-0.74; p = 0.001) were significantly remarkable lower in powered circular stapling group.

CONCLUSION

In this IPTW comparison of patients undergoing rectal reconstructions, the ECP trial cohort had lower risks of several surgical complications AL and statistically signifcant lower rates of ileus/bowel obstruction, infection, and bleeding as Clavien-Dindo ≥ grade II and III as compared with for whom manual circular staplers were used.

Global Surgeon Opinion on the Impact of Surgical Access When Using Endocutters Across Specialties

Background: Despite design enhancements in endocutters, key challenges related to limited surgical access and space can impact stapling and, potentially, surgical outcomes. Objectives: This study aimed to develop consensus statements outlining the clinical value of precise articulation and greater anatomical access in minimally invasive surgery performed by bariatric, colorectal, and thoracic surgeons. Methods: Colorectal, bariatric, and thoracic surgeons from Japan, the United States, United Kingdom, and France participated in a 2-round modified Delphi panel. Round 1 included binary, Likert scale-type, multiple-response, and open-ended questions. These were converted to affirmative statements for round 2 if sufficient agreement was reached. Consensus was set at a predefined threshold of at least 90% of panelists across all surgical specialties and regions selecting the same option ("agree" or "disagree") for the affirmative statements. Results: Of the 49 statements in the round 2 questionnaire, panelists (n=135) reached consensus that (1) tissue slippage outside stapler jaws can occur due to limited access and space; (2) greater jaw aperture could help to manipulate thick or fragile tissue more easily; (3) articulation of an endocutter is clinically important in laparoscopic surgeries; (4) improved access to hard-to-reach targets and in limited space would improve safety; and (5) an endocutter with improved access through greater articulation would become common use. Discussion: By understanding user-specific challenges and needs from both specialty- and region-wide perspectives, endoscopic stapling devices can continue to be refined. In this study, improved articulation and greater jaw aperture were the key design features examined. Improved articulation and greater jaw aperture were key stapler design features identified in this study that may mitigate the risk of instrument clashes and intraoperative complications such as anastomotic leaks. Conclusions: This study gained insights into surgeons' perspective across a variety of specialties and from 3 distinct geographies. Participating surgeons reached consensus that an endocutter with greater jaw aperture and articulation may improve surgical access and has potential to improve surgical outcomes.

Ergonomic Assessment of Surgeon Characteristics and Laparoscopic Device Strain in Gynecologic Surgery

STUDY OBJECTIVE

To evaluate whether surgeon characteristics, including sex and hand size, were associated with grip strength decline with laparoscopic advanced energy devices.

DESIGN

Prospective cohort study.

SETTING

Ergonomic simulation at an academic tertiary care site and the Society of Gynecologic Surgeons 47th Annual Meeting.

PATIENTS

Thirty-eight participants (19 women and 19 men) were recruited.

INTERVENTIONS

Surgeon anthropometric measurements were collected. Each participant completed a 120-second trial of maximum voluntary effort with 3 laparoscopic advanced energy devices (LigaSure, HALO PKS, and ENSEAL). Grip strength was measured using a handheld dynamometer. Subjects completed the NASA Raw Task Load Index scale after each device trial. Grip strengths and ergonomic workload scores were compared using Student t tests and Wilcoxon rank sum tests where appropriate. Univariate and multivariate models analyzed hand size and ergonomic workload.

MEASUREMENTS AND MAIN RESULTS

Women had lower baseline grip strength (288 vs 451 N) than men, as did participants with glove size <7 compared with ≥7 (231 vs 397 N). Normalized grip strength was not associated with surgeon sex (p = .08), whereas it was significantly associated with surgeon glove size (p <.01). Grip strength decline was significantly greater for smaller compared to larger handed surgeons for LigaSure (p = .02) and HALO PKS devices (p <.01). The ergonomic workload of device use was significantly greater for smaller compared to larger handed surgeons (p <.01). Surgeon handspan significantly predicted grip strength decline with device use, even after accounting for potential confounders (R² = .23, β = .8, p <.01).

CONCLUSION

Surgeons with smaller hand size experienced a greater grip strength decline and greater ergonomic workload during repetitive laparoscopic device use. No relationship was found between surgeon sex and grip strength decline or ergonomic workload. Laparoscopic device type was also identified as a significant main effect contributing to grip strength decline. These findings point toward ergonomic strain stemming from an improper fit between the laparoscopic device and the surgeon's hand during device use.

Real-life introduction of powered circular stapler for esophagogastric anastomosis: cohort and propensity matched score study

Anastomotic leakage after esophagectomy is one of the most feared complications, which results in increased morbidity and mortality. Our aim was to evaluate the impact of a powered circular stapler on complications after esophagectomy with intrathoracic anastomosis for esophageal cancer. Between May 2019 and July 2021, all consecutive oesophagectomies for cancer with intrathoracic anastomosis in a high-volume center were included in this retrospective study. Surgeons were free to choose either a manual or a powered circular stapler. Preoperative characteristics and postoperative complications were recorded in a prospective database, according to EsoData. Propensity score matching (age, body mass index, Eastern cooperative oncology group (ECOG) performance and neoadjuvant therapy) was conducted to reduce potential confounding. We included 128 patients. Powered and manual circular staplers were used in 62 and 66 patients, respectively. Fewer anastomotic leakages were observed with the powered stapler group (OR = 7.3 (95%CI: 1.58-33.7); [3.2% (n = 2) vs 19.7% (n = 13), respectively; p = 0.004]). After propensity score matching, this remained statistically significant (OR = 8.5 (95%CI: 1.80-40.1); [4.1% (n = 2) vs 20.4% (n = 10), respectively; p = 0.013]). Additionally, anastomotic diameter was significantly higher with the powered stapler (median: 29 mm (63.3%) vs 25 mm (57.1%), respectively; p < 0.0001). There was no significant difference in comprehensive complication index (p = 0.146). A decreased mean length of stay was observed in the powered stapler group (11.1 vs 18.7 days respectively; p = 0.022). Postoperative anastomotic leakage after esophageal resection was significantly reduced after the introduction of the powered circular stapler, consequently resulting in a reduced length of stay. Further evaluation on long-term strictures and quality of life are warranted to support these results.

Indirect comparison between powered and manual circular staplers for left-sided colorectal anastomoses: clinical and economic outcomes in China

Aims

This study aimed to examine the economic and clinical benefits of a new powered circular stapler for left-sided colorectal construction in China.

Methods

A decision analysis model was constructed for a cohort of adult patients who underwent left-sided colorectal anastomoses, using either the Echelon Circular Powered (ECP) stapler) or the conventional manual circular staplers (MCS). The complications rates and healthcare resource utilization in the ECP cohort were obtained from the single-arm ECP trial (NCT03326895). For the MCS cohort, retrospective data from 20 Chinese hospitals were analyzed. Listing prices were used to estimate the costs of the staplers in China. Propensity score matching (PSM) was employed to adjust for the imbalance between the two cohorts. Anastomotic leak rate, length of stay (LOS), 90-day readmission rate, and direct medical costs were used for the decision analysis model parameters. A budget impact analysis was conducted to compare the total hospitalization expenditure between ECP and manual circular staplers from the hospital’s perspective in China.

Results

Assuming 100 procedures per year, the anastomotic leak rate was 1.79 and 29.76 per 100 procedures in the ECP and MCS cohorts, respectively. LOS was 1,426.91 days in the ECP cohort, compared to 1,702.38 days in the MCS cohort. The 90-day readmission rate was also lower in the ECP cohort than the MCS cohort (19.10 vs. 26.19 per 100 procedures). For the 100 procedures, the annual total hospitalization costs for left-sided colorectal anastomosis were reduced from ¥7,152,251 using manual circular staplers to ¥6,919,306 using ECP. Despite a higher acquisition cost of ECP compared to the manual staplers (¥711,200 vs. ¥441,700), an annual saving of ¥232,945in the total cost resulted from lower rates of complications and shorter LOS. Sensitivity analyses presented consistent savings using ECP, and the ECP cost and cost of the index hospitalization with anastomotic leak were found the most influencing factors.

Conclusions

There were clinical and economic benefits of ECP, compared to manual circular staplers for left-sided colorectal anastomoses. Further direct comparative studies on the use of ECP in practice in Chinese hospital settings are warranted.