Background: Stricture is a common complication of gastrointestinal (GI) anastomoses, associated with impaired quality of life, risk of malnutrition, and further interventions. This systematic review and meta-analysis aimed to determine the association between circular stapler diameter and anastomotic stricture rates throughout the GI tract.
Methods: A systematic literature search of EMBASE, MEDLINE and Cochrane Library was performed. The primary outcome was the rate of radiologically or endoscopically confirmed anastomotic stricture. Pooled odds ratios (OR) were calculated using random-effects models to determine the effect of circular stapler diameter on stricture rates in different regions of the GI tract.
Results: Twenty-one studies were identified: seven oesophageal, twelve gastric, and three lower GI. Smaller stapler sizes were strongly associated with higher anastomotic stricture rates throughout the GI tract. The oesophageal anastomosis studies showed; 21 versus 25 mm circular stapler: OR 4.39 ([95% CI 2.12, 9.07]; P < 0.0001); 25 versus 28/29 mm circular stapler: OR 1.71 ([95% CI 1.15, 2.53]; P < 0.008). Gastric studies showed; 21 versus 25 mm circular stapler: OR 3.12 ([95% CI 2.23, 4.36]; P < 0.00001); 25 versus 28/29 mm circular stapler: OR 7.67 ([95% CI 1.86, 31.57]; P < 0.005). Few lower GI studies were identified, though a similar trend was found: 25 versus 28/29 mm circular stapler: pooled OR 2.61 ([95% CI 0.82, 8.29]; P = 0.100).
Conclusions: The use of larger circular stapler sizes is strongly associated with reduced risk of anastomotic stricture in the upper GI tract, though data from lower GI joins are limited.