Evidence - Anastomosis technique, gastrointestinal, with circular stapler

  1. Literature summary

    Stapled and handsewn anastomoses are equally effective. However, stapled suture lines are not efficient and should therefore be reserved for patient-specific indications.

    It has been shown that stapled and handsewn anastomoses can be fashioned with the same degree of reliability. There was no significant difference between their early / late morbidity and mortality. Except for total colectomy and ileoanal pouch creation, in all studied operations, the surgical procedures studied cost more when the anastomoses were stapled. This is primarily driven by the material cost which accounts for a rather significant part of the total cost. The time saved in some cases by staple suturing and the corresponding decrease in labor cost generally do not favor stapled sutures.

    Surgical staplers are produced in large numbers and supposedly offer an alternative to hand suturing. When handled correctly, one definite benefit of surgical staplers is their time saving standardized use with decreased contamination of the surrounding tissue.

    Pros and cons of surgical staplers


    • Standardized surgical technique
    • Time saving and less contamination of surrounding tissue
    • Less tissue trauma when used correctly
    • Marked expansion of minimally invasive surgical options


    • Given device sizes not necessarily matching the luminal bowel diameter
    • Unreliable anastomosis when the walls are too thick
    • Higher material cost
    • Potential intraluminal anastomotic bleeding
    • Everted approximation with linear staplers

    The use of circular staplers is considered standard technique when fashioning deep rectal anastomoses

    Especially with circular staplers, the rows of staples remain in the tissue and may induce a foreign body reaction with connective tissue proliferation, thus facilitating the development of stenosis.

    Seromuscular double-layering (oversewing the staple line)
    It is postulated that the enzymatic activity of the serosa has a high regenerative potential and therefore appears to be especially important in anastomotic healing. In addition, the serosa is involved in fibrin exudation and fashions an airproof and leakproof seal over the suture line. However, the application of linear staplers leaves everted suture lines with mucosa-mucosa contact. Therefore, oversewing the staple line with a seromuscular suture is recommended. This also prevents the staples from coming into direct contact with neighboring structures.

    To date, no studies have been conducted which conclusively demonstrate the benefits of seromuscular double-layering.

    After stapling, the stapler is withdrawn  from the lumen and both donuts must then be checked for structural integrity along the circular circumference. If these donuts are incomplete, the anastomosis should be oversewn or fashioned anew. Although there is a lack of evidence, the anastomosis is often tested by transanally instilling air or methylene blue.

    In case of bleeding, do not use cautery as this may result in electrical conduction along the metal staples with thermal tissue injury.

    For esophagogastrostomy after esophageal resection, there are no evidence-based recommendations regarding handsewn or stapled anastomosis. While both the handsewn and stapled techniques are safe, stapling causes more stenoses.

    Compared with handsewn anastomosis stapled cervical esophagogastrostomy yielded the best results, presumably because of the constant close contact of the esophagus with the gastric wall and the uniform distribution of tension across the anastomosis.

    With leakage rates of 1%, stapled esophagogastrostomy >is described as the gold standard.

    The more expensive stapled EEA anastomosis yields similar results as the handsewn anastomosis but is easier and faster to perform.

    When inserting a circular stapler, make sure it does not overly dilate the tissue, thereby causing it to tear. In a narrow lumen, i.v. administration of spasmolytics (glucagon, butylscopolamine, etc.) followed by digital or instrumental dilation can be helpful.

    There are no definite indications for staplers in small bowel surgery, apart from the pouch formation and postgastrectomy reconstruction techniques noted above.

    Stapler techniques generally do not offer any benefits in colon surgery.

    Circular staplers are considered the gold standard only when fashioning deep rectal anastomoses. Some authors prefer the so-called double stapling, where the rectum is transected with a linear cutter before the anastomosis is fashioned with a circular stapler.

    In rectal cancer the rate of rectal excision has steadily decreased in recent decades because by now the rectum may be safely resected and anastomosed in the supraanal space of the lesser pelvis.

  2. Ongoing trials on this topic

  3. References on this topic

    Brillantino A, Sandoval Sotelo ML, Cricrì AM, Geraci A, Cricrì M, Scardi F, Monte G, Fusco F, Atelli PF, Antropoli M, Lanza M, Squillante S, Benassai G, Quarto G,  Castriconi M. Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia. J Surg Res. 2022 Sep 14;281:52-56.

    Järvinen T, Cools-Lartigue J, Robinson E, Räsänen J, Ilonen I. Hand-sewn versus stapled anastomoses for esophagectomy: We will probably never know which is better. JTCVS Open. 2021 Jul 28;7:338-352.

    Angehrn FV, Neuschütz KJ, Fourie L, Becker P, von Flüe M, Steinemann DC, Bolli M. Continuously sutured versus linear-stapled anastomosis in robot-assisted hybrid Ivor Lewis esophageal surgery following neoadjuvant chemoradiotherapy: a single-center cohort study. Surg Endosc. 2022 Jul 19.

    Brunner M, Zu'bi A, Weber K, Denz A, Langheinrich M, Kersting S, Weber GF, Grützmann R, Krautz C. The use of single-stapling techniques reduces anastomotic  complications in minimal-invasive rectal surgery. Int J Colorectal Dis. 2022 Jul;37(7):1601-1609.

    Paskoff KM, Hlusko KC, Buirkle CL, Coggeshall WS, Matz BM, Linden DS. Influence of stapler type on in vitro leakage pressures and location of functional end-to-end stapled anastomoses. Can J Vet Res. 2022 Apr;86(2):113-115.

    Oesophago-Gastric Anastomosis Audit study group on behalf of the West Midlands Research Collaborative.. The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit. J  Thorac Cardiovasc Surg. 2022 Sep;164(3):674-684.e5.

    Yang ML, Brar MS, Boughn A, Saini J, Kennedy E, MacRae H, de Buck Van Overstraten A. Does Oversewing Stapled Ileocolic Anastomoses for Crohn's Disease Reduce Anastomotic Complications? An Inverse-Probability Weighting Analysis of a Single  Centre Cohort. J Gastrointest Surg. 2022 Feb 17.

    Rajan R, Arachchi A, Metlapalli M, Lo J, Ratinam R, Nguyen TC, Teoh WMK, Lim JT,  Chouhan H. Ileocolic anastomosis after right hemicolectomy: stapled end-to-side,  stapled side-to-side, or handsewn? Int J Colorectal Dis. 2022 Mar;37(3):673-681.

    Enomoto H, Ito M, Sasaki T, Nishizawa Y, Tsukada Y, Ikeda K, Hasegawa H. Anastomosis-Related Complications After Stapled Anastomosis With Reinforced Sutures in Transanal Total Mesorectal Excision for Low Rectal Cancer: A Retrospective Single-Center Study. Dis Colon Rectum. 2022 Feb 1;65(2):246-253.

    Hosoi T, Abe T, Higaki E, Fujieda H, Nagao T, Ito S, Komori K, Iwase M, Oze I, Shimizu Y. Circular Stapled Technique Versus Modified Collard Technique for Cervical Esophagogastric Anastomosis After Esophagectomy: A Randomized Controlled Trial. Ann Surg. 2022 Jul 1;276(1):30-37.

    Hudson D, Entriken F, Hodder R, Warner M. Functional outcomes and local control are acceptable following hand-sewn colo-anal anastomoses for rectal cancer: Results of long-term follow-up. ANZ J Surg. 2022 Mar;92(3):390-396.

    Illuminati G, Pasqua R, Perotti B, Urciuoli P, Nardi P, Fratini C, Carboni F, Valle M. Standard versus eversion-modified double-staple technique for low colorectal anastomoses after resection of rectal cancer. Surg Today. 2021 May;51(5):785-791.

    Sigmon DF, Lopez PP. Gastrojejunostomy. 2022 May 2. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

    Hu J, Zhao L, Xue H, Zhang Z, Du J. Predominant classic circular-stapled double-tract reconstruction after totally laparoscopic proximal gastrectomy: safe, feasible, time-saving anastomoses by technical tie-up. Surg Endosc. 2020 Nov;34(11):5181-5187.

    Luo W, Qian C, Lu T, Zhang L, Sun M, Li F, Xu Z, Jia Y. A Modified Side-to-Side Anastomosis Using a Circular Stapler Reduces Anastomotic Leakage in Colonic Surgery. Surg Innov. 2020 Apr;27(2):143-149.

    Luglio G, Corcione F. Stapled versus handsewn methods for ileocolic anastomoses.  Tech Coloproctol. 2019 Nov;23(11):1093-1095.

    Nordholm-Carstensen A, Schnack Rasmussen M, Krarup PM. Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study. Dis Colon Rectum. 2019 May;62(5):542-548. 


Schlottmann F, Angeramo CA, Bras Harriott C, Casas MA, Herbella FAM, Patti MG. Transthoracic Esopha

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