Safety of Small Circular Staplers in Double Stapling Technique Anastomosis for Sigmoid Colon and Rectal Cancer.

Background Although smaller circular staplers are easier to insert and less likely to involve the vagina and levator ani muscles when performing double stapling technique anastomosis, surgeons often consider that larger circular staplers would be safer in reducing the risk of postoperative anastomotic strictures. Objective This study aimed to investigate the safety of using 25-mm circular staplers compared to 28/29-mm staplers in the double stapling technique anastomosis regarding the development of anastomotic strictures and other complications. Design Retrospective observational study. Setting Single comprehensive cancer center. Patients Consecutive patients undergoing curative colorectal resection with double stapling technique anastomosis for stage I-III sigmoid colon and rectal cancer between 2013 and 2016 were included. Main outcome measures Incidence of anastomotic complications (strictures, leakage, and bleeding) were compared between the 25- and 28/29-mm circular staplers. Predictors for anastomotic strictures were investigated with multivariable logistic regression. Results Among a total of 815 eligible patients, 25-mm staplers were used in 186 (22.8%). The 25-mm staplers were associated with use in female patients, splenic flexure take-down, high tie of the inferior mesenteric artery, and low anastomosis. Overall anastomotic complications (11.8% vs. 13.7%, p=0.51), strictures (5.9% vs. 3.3%, p=0.11), leakage (2.7% vs. 3.8%, p=0.47), and bleeding (4.8% vs. 7.6%, p=0.19) were not different between the 25- and 28/29-mm staplers. From multivariable logistic regression, independent predictors of anastomotic strictures included diverting ostomy and anastomotic leakage, but did not include small circular stapler use. Most of the 32 anastomotic strictures were successfully treated without surgical intervention (finger dilatation, N=25; endoscopic intervention, N=5). Limitations This was a single-center retrospective study. Conclusions Use of 25-mm circular staplers for double stapling technique anastomosis is safe and does not increase the risk of anastomotic strictures and other anastomotic complications when compared to larger staplers. See Video Abstract at http://links.lww.com/DCR/B576 .