Impact of the number of stapler firings on anastomotic leakage in laparoscopic rectal surgery: a systematic review and meta-analysis

Background Several univariate and multivariate studies have already identified the number of stapler firings for laparoscopic rectal transection for rectal cancer as an independent risk factor for anastomotic leakage. The aim of this study was to perform a systematic review and meta-analysis of the anastomotic leakage rate in laparoscopic rectal surgery according to the need of using one or two stapler firings for rectal transection. Methods PubMed, Ovid, the Cochrane Library database and ClinicalTrials.gov were searched. All of the statistical analyses were performed using Revman software. Results Five studies were included (1267 patients). The overall anastomotic leakage rate was 5.5% [0.7–8.4%]. Anastomotic leak occurred in 3.5% (17/491) of the cases where 1 stapler firing was used versus 6.7% (50/786) of the cases in which 2 firings were needed (50/786). Two stapler firings were significantly associated with an increased risk of anastomotic leakage (OR 2.44, 95% CI 1.34–4.42, p = 0.003, I 2 = 1%). Conclusions Our systematic review and meta-analysis suggest that two firings imply a higher rate of anastomotic leak than a single firing after laparoscopic rectal surgery with a double stapling technique. Coloproctologists should strive to reduce the number of linear stapler firings and try to transect the rectum with a single firing.