EP550 - Clinical and Economic Outcomes of Circular Staplers Used in Colorectal Procedures

Purpose/Background: When compared to two-row manual circular staplers, recent systematic review studies showed that both the three-row circular stapler (TRCS) and powered circular stapler (PCS) were likely to reduce anastomotic leak when used in left-sided colorectal anastomoses. However, there is no study that has directly compared the outcomes between the use of TRCS and PCS. The aim of this study is to compare the clinical and economic outcomes of using these two types of staplers (TRCS and PCS) in left-sided colorectal anastomoses.

Methods/Interventions: PINC AI™ Healthcare Data (PHD) was used for conducting the study. We included patients aged ≥ 18 who underwent elective left colectomy or rectal resection with colorectal anastomosis between 1/1/2020 and 6/30/2024 using either TRCS or PCS with no missing age/sex data, and cost >0. Outcomes analyzed included anastomotic leak, bleeding, blood transfusion, infection, device/surgical complication, 30-day emergency room readmission, length of stay, operating room (OR) time, and total inpatient costs in 2024 USD. 1:6 nearest neighbor propensity scores matching (PSM) for TRCS and PCS based on patients' and providers' characteristics, and a caliper of 0.2 was used for adjusted imbalance of baseline characteristics in the two groups. Sensitivity analysis was used with generalized linear models (GLMs).

Results/Outcomes: 5724 cases (93.8% PCS, 6.2% TRCS) were included; 1703 PCS and 292 TRCS cases were matched after PSM. The standard differences of patient baseline characteristics before and after PSM are shown in the Figure. Patients who used PCS had 2.7% higher bleeding rates (95% confidence interval (CI): 0.01%, 5.4%, p< 0.05), and longer operating room time (mean difference: 55 minutes (95% CI: 21, 88, p< 0.05) than those who used TRCS. There is no significant statistical difference between the two groups in anastomotic leak, blood transfusion, surgical/device complications, ICU visit, 30-day emergency room readmission, and total inpatient costs. GLMs yielded similar results to PSM in all outcome comparisons, except for the infection outcome.

Conclusion/Discussion: The study results showed that there was a statistically significantly higher rate of bleeding and longer operative time when using the PCS compared to the TRCS. This study suggests that using TRCS may be more efficient in the operating room than PCS, given the difference in operating times. This may be due to a number of factors. Due to the larger volume of cases analyzed using the PCS, there may have been more variation in technique and operative difficulty, which added time to the operation not attributed to stapler use. A few other factors that may contribute to slightly longer operative times when using PCS include setup and battery connection, power checks and calibration, firing time at slower fixed rates, and OR staff familiarity with the powered stapler. There was no statistical difference in all of the other clinical and economic outcomes for patients in which a TRCS or PCS was used for left-sided colorectal anastomoses. This study does have limitations due to the nature of the claims database. This may result in the misclassification of complications and lack of details regarding the stapler used to identify the root cause of the study findings. Further clinical studies are warranted to understand the casualty of these findings.

Mean standard differences across covariates before and after propensity scores matching
This figure demonstrates the mean standard differences of the covariates between the powered circular stapler and the three-row circular stapler before and after propensity score matching.