QS300 - Can We Right the Ship? Navigating EEA Stapler Complications in Colorectal Surgery

Tuesday, May 13, 2025

8:05 AM – 8:08 AM PT

Location: Room 9, Upper Level

Quick Shot Presenter(s)

Jonathan T. Bliggenstorfer, MD

Fellow in Colon and Rectal Surgery
Lahey Clinic
Burlington, MA, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

PS

Pharis B. Sasa, MD

Resident in General surgery
The Lahey Clinic
Waltham, Massachusetts, United States

Disclosure information not submitted.
James G. Connolly, MD

Fellow
Lahey Hospital and Medical Center
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
Racquel S. Gaetani, MD (she/her/hers)

General Surgery Resident/Colorectal Research Fellow
LAHEY HOSPITAL AND MEDICAL CENTER
Lahey Hospital and Medical Center
Burlington, MA, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
CM

Cody W. Munroe, MS

Coordinator
Lahey Hospital and Medical Center
Burlington, Massachusetts, United States

Disclosure information not submitted.
AK

Angela H. Kuhnen, MD, MPH (she/her/hers)

Attending
Lahey Hospital and Medical Center
Tufts University School of Medicine
Burlington, Massachusetts, United States

All of the relevant financial relationships listed below have been mitigated.
Applied Medical: Teaching (Terminated, April 5, 2024); Medtronic: Consultant (Terminated, June 12, 2024)
Peter W. Marcello, MD (he/him/his)

Attending
Lahey Hospital and Medical Center
Burlington, Massachusetts, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no relevant relationships with ineligible companies.
JS

Julia T. Saraidaridis, MD, MMSc

Assistant Professor of Surgery, Tufts University School of Medicine
Lahey Clinic
Burlington, Massachusetts, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
Jonathan S. Abelson, MD MS (he/him/his)

Staff Surgeon
Lahey Hospital and Medical Center
Tufts Medical Center
Arlington, Massachusetts, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Senior Author(s)

David A. Kleiman, MD, MSc, FACS, FASCRS (he/him/his)

Staff Surgeon, Division of Colon & Rectal Surgery
Lahey Hospital & Medical Center
Melrose, Massachusetts, United States

All of the relevant financial relationships listed below have been mitigated.
Applied Medical: Consultant (Ongoing), Grant/Research Support (Ongoing), Teaching (Ongoing); Intuitive: Honoraria (Ongoing); Noah Medical: Consultant (Ongoing)

All of the relevant financial relationships listed below have been mitigated.

Jonathan T. Bliggenstorfer, MD: This individual has no financial relationships with ineligible companies.

James G. Connolly, MD: This individual has no financial relationships with ineligible companies.

Racquel S. Gaetani, MD: This individual has no financial relationships with ineligible companies.

Angela H. Kuhnen, MD, MPH: Applied Medical: Teaching (Terminated, April 5, 2024); Medtronic: Consultant (Terminated, June 12, 2024)

Peter W. Marcello, MD: This individual has no relevant relationships with ineligible companies.

Julia T. Saraidaridis, MD, MMSc: This individual has no financial relationships with ineligible companies.

Jonathan S. Abelson, MD MS: This individual has no financial relationships with ineligible companies.

David A. Kleiman, MD, MSc, FACS, FASCRS: Applied Medical: Consultant (Ongoing), Grant/Research Support (Ongoing), Teaching (Ongoing); Intuitive: Honoraria (Ongoing); Noah Medical: Consultant (Ongoing)

Image or Table (Do Not add text here):

Purpose/Background: End-to-end anastomotic (EEA) staplers are commonly used in colorectal surgery to create secure connections between the rectum and proximal bowel. However, EEA staplers can lead to technical complications such as bleeding, incomplete tissue donuts, and positive air leaks. Management algorithms for these complications and their impact on surgical outcomes is unclear. This study seeks to evaluate the incidence of intraoperative EEA complications for colorectal anastomoses, review their management, and evaluate 30-day outcomes.

Methods/Interventions: A prospectively maintained database was reviewed to identify all EEA stapled anastomoses performed by colorectal surgeons at a high-volume tertiary care center between 04/2021 and 08/2024. Intraoperative flexible endoscopy is routinely performed following creation of the anastomosis. Cases with intraoperative EEA complications were identified, including anastomotic bleeding, incomplete donuts, and positive air leak test. Operative notes were reviewed to identify interventions undertaken to repair the complication. Subsequent postoperative outcomes were evaluated, including blood transfusions, unplanned post-operative interventions, and major 30-day complications, such as readmission, stroke, myocardial infarction (MI), surgical site infection (SSI), and pulmonary embolism (PE).

Results/Outcomes: 626 EEA stapled anastomosis were performed. 87 (13.9%) experienced an intraoperative EEA-related event: 68 instances of intraoperative anastomotic bleeding, 14 instances of positive air leak tests, and 7 incomplete donuts. Of the anastomotic bleeds, 65 (95.6%) were controlled with suture and 3 (4.4%) with endoscopic clipping. No patients required post-operative interventions or blood transfusion for bleeding. Among the 14 positive air leaks, 3 (21.4%) occurred at the rectal stump staple line, of which 2 (14.3%) were managed by incorporating the leak site into the EEA anastomosis and 1 (7.1%) with revision of the rectal stump. The remaining 11 (78.6%) air leaks occurred at the EEA staple line, 9 (64.3%) managed with suture reinforcement, 1 (7.1%) with anastomotic revision, and 1 (7.1%) with proximal diversion only. Of the 9 EEA air leaks that underwent suture reinforcement, 2 (22.2%) remained positive and underwent proximal fecal diversion, and 7 (77.8%) remained airtight. Among the 7 incomplete donuts, 5 (71.4%) were reinforced with suture and 6 (85.7%) had proximal fecal diversion. Only 1 case had both an incomplete donut and a positive air leak test.

Among the 20 patients with either a positive air leak test or an incomplete donut, 16 (80.0%) were diverted, all of whom were planned pre-operatively. Only 2 (10.0%) developed post-operative anastomotic leaks, both of whom had been diverted. Three patients required additional post-operative interventions, 1 undergoing endoscopy, 1 drain placement by interventional radiology, and one requiring both procedures. The 30-day complication rate was low, with only 7 (8.1%) patients requiring readmission. Rates of MI, PE, stroke, pneumonia and SSI were below 3%.

Conclusion/Discussion: Technical complications during EEA stapling occurred in roughly 1 in 6 patients. In this cohort, prompt recognition and appropriate intraoperative management successfully minimized adverse outcomes. Intraoperative flexible endoscopy aids in identification of anastomotic complications, guiding the surgeon’s management decisions for anastomotic repair, revision, or proximal fecal diversion.