Stapler Firing Count Predicts Anastomotic Leak: A Retrospective Study on Colorectal Cancer Surgery

<b><i>Purpose:</i></b> The aim of this study is to evaluate whether the number of linear stapler firings used during rectal division influences the rate of anastomotic leakage (AL) in patients undergoing left hemicolectomy, sigmoidectomy, or anterior resection for cancer. <b><i>Methods:</i></b> This is a retrospective analysis of prospectively collected data. All consecutive patients with left or sigmoid colon or rectal cancer who underwent elective resection with primary anastomosis from 2013 to 2025 were included. Patients were categorized into three groups according to the number of linear stapler firings used to divide the rectum: rectal division with one stapler firing (group A), rectal division with two stapler firings (group B), and rectal division with three or more stapler firings (group C). <b><i>Results:</i></b> One hundred and sixty patients were included in group A, 68 patients in group B, and 17 patients in group C. The overall AL rate was 8.2% and rose significantly when multiple stapler firings were used (4.4% versus 13.2% versus 23.5% in groups A, B, and C, respectively; A versus B: <i>P</i> = .04; A versus C: <i>P</i> ≤ .01; B versus C: <i>P</i> = .55). Multivariate analysis confirmed multiple firings as an independent predictor of AL (two stapler firings: odds ratio [OR] = 3.06, <i>P</i> = .04; three or more stapler firings: OR = 5.04, <i>P</i> = .02). <b><i>Conclusions:</i></b> Multiple stapler firings during rectal transection are linked to increased rates of AL compared with the use of a single stapler firing. Prospective, multicenter trials are needed to validate these findings and to improve anastomotic safety in left colon, sigmoid, and rectal cancer surgery.