EP452 - Impact Of Stapler Firing Number On Anastomotic Leakage In Minimally Invasive Rectal Surgery: A Meta-Analysis And Meta-Regression

Sunday, May 10, 2026

1:46 PM - 1:51 PM ET

ePoster Presenter(s)

Stefano Cardelli (he/him/his)

MD - PhD student
Bologna University Hospital - IRCCS Sant'Orsola Malpighi
Bologna University
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.

Author(s)

EB

Elena Brusa, n/a

MD - General surgery resident
Bologna University Hospital - IRCCS Sant'Orsola Malpighi
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.
GC

Giacomo Calini, MD

Assistant Professor of Surgery
Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.
TV

Tommaso Violante, n/a

MD - PhD student
Bologna University Hospital - IRCCS Sant'Orsola Malpighi
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.
AG

Alice Gori, n/a

General Surgery Resident
University of Bologna
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.
DC

Dajana Cuicchi, n/a

MD
Bologna University Hospital - IRCCS Sant'Orsola Malpighi
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.
LS

Luca Stocchi, MD,MBA

chair division of colorectal surgery
mayo clinic
Mayo Clinic Florida
Jacksonville, FL, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Senior Author(s)

MR

Matteo Rottoli, n/a

Chief of Robotic Surgery
Alma Mater Studiorum University of Bologna
Bologna, Emilia-Romagna, Italy

Disclosure information not submitted.

All of the relevant financial relationships listed below have been mitigated.

Luca Stocchi, MD,MBA: This individual has no financial relationships with ineligible companies.

Purpose/Background: Anastomotic leakage (AL) is a major complication after minimally invasive anterior resection for rectal cancer. The number of stapler firings (SFs) used for rectal transection has been proposed as a modifiable risk factor, but its independent role and optimal threshold remain uncertain. This meta-analysis examined the association between SF count and AL risk, accounting for surgical and patient-related variables.

Methods/Interventions: A systematic review and meta-analysis were conducted in accordance with the PRISMA 2020 guidelines and registered in PROSPERO (CRD420251062761). PubMed, Cochrane Library, and Ovid MEDLINE were searched up to May 2025. Eligible studies included patients who underwent laparoscopic or robotic rectal resection with primary anastomosis using a double-stapled technique and reported AL rates by SF category (1, 2, ≥3). Pooled odds ratios (ORs) with 95% CIs were calculated using random-effects models. Meta-regression analysis assessed the influence of rectal transection height, BMI, sex, and preoperative radiotherapy.

Results/Outcomes: Twenty studies (10,989 patients; 731 AL events) were analyzed. Single firing significantly reduced AL risk compared with 2 SFs (OR 0.57, 95% CI 0.39–0.83), ≥2 SFs (OR 0.47, 95% CI 0.34–0.64), and ≥3 SFs (OR 0.31, 95% CI 0.18–0.57). AL risk was lower for < 3 versus ≥3 firings (OR 0.38, 95% CI 0.29–0.49). Meta-regression analysis identified low rectal transection (β = 6.44, p = 0.033) and preoperative radiotherapy (β = 3.47, p = 0.021) as significant moderators of the association between SFs and AL. Heterogeneity was minimal across comparisons; nonetheless, all studies were observational and at moderate risk of bias.

Conclusion/Discussion: A higher number of SFs during rectal transection consistently correlates with increased AL risk, particularly with three or more firings. However, this link appears to be primarily influenced by technical complexity factors, such as a low anastomotic level and prior radiotherapy. These results indicate that the SF count may reflect overall surgical complexity rather than being a modifiable factor. Clarifying whether it functions as a surrogate marker of technical difficulty or directly increases AL risk is crucial to optimize the role of single-stapling techniques in complex rectal surgeries.