Surgical Endoscopy (2018) 32:3122–3130
Does advancement in stapling technology with triple-row
and enhanced staple conﬁgurations confer additional safety?
A matched comparison of 340 stapled ileocolic anastomoses
Chi Chung Foo
· Alston Ho On Chiu
· Jeremy Yip
· Wai Lun Law
Received: 13 March 2017 / Accepted: 3 January 2018 / Published online: 16 January 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Background Over the past few decades, studies have focused on the safety of stapled anastomosis, especially when compared
to that of the handsewn technique. However, studies on the improvement of stapling technology are limited. This study aimed
to investigate whether linear triple-row staples (tri-staples) had any advantage over double-row staples.
Methods This is a retrospective review of all cases of functional end-to-end anastomoses with linear staplers performed at
two centers between 2005 and 2015. Data were retrieved from a prospectively maintained database. Cases of anastomoses
performed with double-row (DS) and triple-row (TS) staples were matched according to propensity scores. The rates of
anastomotic leakage, bleeding, reoperation, and 30-day mortality were compared.
Results Functional end-to-end ileocolic anastomoses were performed in 563 consecutive patients during the study period.
Double- and triple-row stapling devices were used in 389 and 174 anastomoses, respectively. With propensity score matching,
170 cases were chosen from each group. Both groups showed comparable baseline characteristics. The anastomotic leakage,
anastomotic bleeding, and intra-abdominal collection rates were 2.4 and 0% (p = 0.123), 1.2 and 0% (p = 0.499), and 3.5
and 1.2% (p = 0.283) for DS and TS, respectively. The reoperation and 30-day mortality rates were 5.9 and 1.8% (p = 0.048)
and 0.6 and 1.2% (p = 1.000) for DS and TS, respectively. The median lengths of stay were 5 and 6 days (p = 0.072) for DS
and TS, respectively.
Conclusion Anastomoses with triple-row staples tended to have a lower morbidity rate, but a signiﬁcant advantage over
double-row staples was not demonstrated in this study.
Keywords Stapler · Ileocolic anastomosis · Anastomotic leakage
Colonic resections with subsequent ileocolic anastomoses
are commonly performed colorectal operations. Morbidities
following right-sided colonic resections with ileocolic anas-
tomosis are believed to be less common than those following
left-sided resections with colo-colonic anastomosis [1–3].
However, anastomotic complications do occur, and the con-
sequence can be widespread, given the large volume of these
procedures . Anastomotic leakage invariably increases
the length of hospital stay, aﬀects the quality of life, and
increases the chance of mortality [5–9].
Surgical stapling devices were ﬁrst described by Hültl in
1908 and have since been used for creating anastomoses [10,
11]. Staplers were particularly relevant in low anastomoses.
The optimal method of bowel anastomosis is still debatable
despite numerous studies on the techniques and suture mate-
However, only a few studies in the literature are focused
on the ongoing improvement in stapling technology. One
such improvement is the addition of one row of staples, that
is, three staggered rows of staples, as compared with the con-
ventional two rows, to seal tissue. Another advancement was
a modiﬁed conﬁguration of the closed staples. This invari-
ably increases the cost of the stapling device. Whether this
results in clinical beneﬁt is yet to be answered. This study
aimed to compare the clinical outcomes of anastomoses with
linear double-row stapling devices and stapling devices with
triple-row and enhanced staple conﬁgurations.
and Other Interventional Techniques
* Chi Chung Foo
Department of Surgery, Queen Mary Hospital, The
University of Hong Kong, 102 Pokfulam Road, Hong Kong,