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Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?



Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections.


A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25–29 mm or 30–33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications.


Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25–29 mm group and 288 (60.9%) in the 30–33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30–33 mm than with the 25–29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25–29 mm than with the 30–33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032).


The 25–29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30–33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.

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Correspondence to D. S. Keller.

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The project was approved by the Institutional Review Board at Columbia University Medical Center (Protocol #AAAS0610). The study is reported according to the STROBE checklist for cohort studies (

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Reif de Paula, T., Simon, H., Shah, M. et al. Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?. Tech Coloproctol 24, 283–290 (2020).

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  • Colorectal neoplasms
  • Anastomosis
  • surgical
  • Elective surgical procedures
  • Constriction
  • pathologic
  • Surgical stapler
  • Anastomotic leak
  • Outcome assessment
  • health care