The "double-fired" gastro-jejunostomy as a form of improved efficiency during Whipple procedure.

BACKGROUND: Gastro-jejunostomy (GJ) after pylorus-resecting pancreatoduodenectomy (PD) is most commonly performed in a hand-sewn fashion. Intestinal stapled anastomosis are reported to be as effective as hand-sewn in terms of patency and risk of leakage in other indications. However, the use of a stapled gastro-jejunostomy hasn't been fully assessed in PD. The aim of the present technical report is to evaluate functional outcomes of stapled GJ during PD, its associated effect on operative time and related complications. METHODS: The institutional database for pancreatic duct adenocarcinoma (PDAC) was retrospectically reviewed. Pylorus resecting open PD without vascular or multivisceral resections were considered for the analysis. The incidence of clinically significant delayed gastric emptying (DGE from the International Stufy Group of Pancreatic Surgery (ISGPS) grade B and C), other complications, operative time and overall hospitalization were evaluated. RESULTS: Over a 10-years study period, 1182 PD for adenocarcinoma were performed and recorded in the database. 243 open Whipple procedures with no vascular and with no associated multivisceral resections were available and constituted the study population. Hand-sewn (HS) anastomosis was performed in 175 (72 %), stapled anastomosis (St) in 68 (28 %). No significant differences in baseline characteristics were observed between the two groups, with the exception of a higher rate of neoadjuvant chemotherapy in the HS group (74 % St vs. 86 % HS, p = 0.025). Intraoperatively, a significantly reduced median operative time in the St group was observed (248 min St vs. 370 mins HS, p < 0.001). Post-operatively, rates of clinically relevant delayed gastric emptying (7 % St vs. 14 % HS, p = 0.140), clinically relevant pancreatic fistula (10 % St, 15 % HS, p = 0.300), median length of stay (7 days for each group, p = 0.289), post-pancreatectomy hemorrhage (4.4 % St vs. 6.3 % HS, p = 0.415) and complication rate (22 % St vs. 34 % HS, p = 0.064) were similar between groups. However, readmission rates were significantly lower after St GJ (13.2 % St vs 29.7 % HS, p = 0.008). CONCLUSION: Our results indicate that a stapled GJ anastomosis during a standard Whipple procedure is non-inferior to a hand-sewn GJ, with a comparable rate of DGE and no increase of gastrointestinal related long term complications. Further, a stapled GJ anastomosis might be associated with reduced operative times.

Comparison of the postoperative outcome with and without intraoperative leak testing for sleeve gastrectomy: a systematic review and meta-analysis of 469 588 cases.

OBJECTIVE: Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG. METHODS: The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates. RESULTS: Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05). CONCLUSION: IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.

Effect of suture closure and staple closure on postoperative wound complications in patients undergoing knee replacement surgery: A meta-analysis.

The purpose of this meta-analysis is to determine if the application of stitching in the closed area of the knee arthroplasty remains significantly superior to that of the staples. Data sources: EMBASE, Cochrane Libraryand, publications, and the Web of Science. Patients were treated with staples for closure of their wounds, or with conventional stitches for closure of wounds. The main findings were surgical site infection, wound dehiscence, and cutting time. The secondary results were the time to completion, the duration of the hospitalization, and the time to discharge. We incorporated the SIX trial into the meta-analyses with Review Manager V.5.3. The hazard ratio was computed as a therapeutic outcome with respect to the heterogeneity. For more than 50% of heterogeneous samples, we employed a stochastic effect model. The results showed that there was no significant difference in the degree of infection, the degree of dehiscence, the length of the cut and the degree of satisfaction of the wound. But the time to close the wound and the time to operate were significantly different. The time needed to close the wound was shorter than that of the suture (OR, -227. 22; 95% CI, -238. 74, -215. 69 p < 0. 0001); The time taken to replace the knee was also significantly lower among those who had been stapled sutures (OR, -5.46; 95% CI, -10. 43, -0.49 p = 0. 03). Wound closing materials are an afterthought for many orthopaedic surgeons. Together, the findings from a number of comparative studies indicate that the selection of wound closure materials might affect the outcome of the surgery. The evidence, however, is weak because of the heterogeneous approach adopted in earlier research. This study program is intended to provide guidance on how to select the best wound closure material for the purpose of identifying if there is any difference in the incidence of injuries among traditional stitches and staples.

Mechanical properties and tissue damage caused by staples in gastrointestinal anastomosis.

Gastrointestinal surgery using a stapler is usually associated with tissue damage, anastomosis leakage, bleeding, and other complications, which is one of the effective methods for treating digestive tract cancer. The cutting properties of staples and the tissue damage occurring in the process of stapling porcine esophageal and gastric tissues have been evaluated and a new type of stapler has been designed. Since different structural and mechanical properties esophageal and gastric tissues layers, the puncturing force exhibits a fluctuating trend. Compressive stress caused by the bending of the staple legs can lead to the destruction of the vascular network inside the tissue, tissue deforms and tears. Finally, a staple with an internal incision arc (IIA) tip is designed, which meeting the performance requirements.

Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model.

Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid-low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15-5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20-4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid-low rectal cancer patients.

Risk of anastomotic leakage with two-row versus three-row manual circular staplers in colorectal anastomosis: a U.S. cohort study.

PURPOSES: To compare the risk of anastomotic leak (AL) between Ethicon manual circular staplers (two-row) versus Medtronic EEA™ circular stapler with Tri-Staple™ technology (three-row) and between Medtronic EEA™ circular stapler with DST™ Series technology (two-row) versus Tri-Staple™ technology. METHODS: A retrospective cohort study was conducted in adult patients who underwent a left-sided colorectal surgery 2019-2022 in U.S. Premier Healthcare Database to assess the risk of AL within 30 days post-index procedure. The study devices were Ethicon manual circular staplers, Medtronic EEA™ circular stapler with DST™ technology, and Medtronic EEA™ circular stapler with Tri-Staple™ technology. RESULTS: Across 447 hospitals, the cumulative incidences (95% confidence intervals [CI]) of AL within 30 days post-index procedure were 7.78% (6.91-8.74%) among 8337 patients in the Ethicon manual circular stapler cohort, 7.54% (6.87-8.27%) among 7928 patients in the Medtronic EEA™ circular stapler with DST™ technology cohort, and 8.19% (6.57-10.07%) among 1306 patients in the Medtronic EEA™ circular stapler with Tri-Staple™ technology cohort. Comparative analyses revealed no difference comparing Ethicon manual circular staplers with Medtronic EEA™ circular staplers with Tri-Staple™ technology (risk ratio [RR], 0.72; 95% CI, 0.52-1.01) or comparing Medtronic EEA™ circular staplers with DST™ technology to Tri-Staple™ technology (RR, 0.75; 95% CI, 0.53-1.06). CONCLUSION: In this analysis of a large cohort of patients undergoing a left-sided colorectal surgery from a U.S. hospital database, the risk of AL observed with manual two-row circular staplers was similar to that seen with three-row devices. This study affirms the safety of manual two-row circular staplers in colorectal anastomosis.

Impact of powered circular stapler on anastomotic leak after anastomosis to the rectum: a propensity score matched study.

PURPOSE: The aim of the present study is to assess the impact of Echelon Circular™ powered stapler (PCS) on left-sided colorectal anastomotic leaks and to compare results to conventional circular staplers (CCS). METHODS: A single center cohort study was carried out on 552 consecutive patients, who underwent laparoscopic colorectal resection and anastomosis to the rectum between December 2017 and September 2022. Patients who underwent powered circular anastomosis to the rectum were matched to those who had a conventional stapled anastomosis using a propensity score matching. Main outcomes were anastomotic leak (AL) rate, anastomotic bleeding, and postoperative outcomes. RESULTS: After adjusting cases with propensity score matching, two new groups of patients were generated: 145 patients in the PCS and 145 in the CCS. The two groups were homogeneous with respect to demographics and comorbidities on admission. Overall, AL occurred in 21 (7.3%) patients. No significant differences were observed with respect to AL (5.5% in PCS vs 9% in CCS; p = 0.66), fistula severity (p = 0.60) or reoperation rate (p = 0.65) in the two groups in study. A higher rate of anastomotic bleeding was observed in the CCS vs PCS (5.5% vs 0.7%, p = 0.03). At univariate analysis performed after propensity score matching, stapler diameter ≥ 31mm and age ≥ 70 years were the only variable significantly associated with anastomotic leak (p = 0.001 and p = 0.031; respectively). CONCLUSIONS: The powered circular stapler has no impact on AL, while it could affect bleeding rate at the anastomotic site.

Factors Related to Bleeding and Leak Rates After Robotic Sleeve Gastrectomy.

BACKGROUND: Robotic sleeve gastrectomy has been increasing in annual incidence in recent years. Although rare, post op bleeding and leak in these cases can lead to significant morbidity, mortality, and healthcare utilization. OBJECTIVES: To determine preop comorbidity risk factors and operative techniques associated with risk of bleeding or leak within 30 days of robotic sleeve gastrectomy. METHODS: The MBSAQIP database was analyzed. A total of 53,548 RSG cases were included in analysis. Surgeries took place from accredited centers in the USA from 2015 to 2019. CONCLUSIONS: Preoperative anticoagulation, renal failure, COPD, and OSA were found to increase in the risk for transfusion requirements after SG. Receiving a transfusion and smoking increased the risk for leak. Staple line reinforcement significantly decreased transfusion and leak rates. Staple line oversewing did not have an impact on bleeding or leak.

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts.

BACKGROUND: Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. MATERIALS AND METHODS: A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026). CONCLUSION: The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.

Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies.

Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.

Perirectal hematoma after stapled surgery for hemorrhoidal prolapse and obstructed defecation syndrome: case series management to avoid panic-guided treatment.

Perirectal hematoma (PH) is one of the most feared complications of stapling procedures. Literature reviews have reported only a few works on PH, most of them describing isolated treatment approaches and severe outcomes. The aim of this study was to analyze a homogenous case series of PH and to define a treatment algorithm for huge postoperative PHs. A retrospective analysis of a prospective database of three high-volume proctology units was performed between 2008 and 2018, and all PH cases were analyzed. In all, 3058 patients underwent stapling procedures for hemorrhoidal disease or obstructed defecation syndrome with internal prolapse. Among these, 14 (0.46%) large PH cases were reported, and 12 of these hematomas were stable and treated conservatively (antibiotics and CT/laboratory test monitoring); most of them were resolved with spontaneous drainage. Two patients with progressive PH (signs of active bleeding and peritonism) were submitted to CT and arteriography to evaluate the source of bleeding, which was subsequently closed by embolization. This approach helped ensure that no patients with PH were referred for major abdominal surgery. Most PH cases are stable and treatable with a conservative approach, evolving with self-drainage. Progressive hematomas are rare and should undergo angiography with embolization to minimize the possibility of major surgery and severe complications.

Risk Factors of Anastomosis Stricture After Esophagectomy and the Impact of Anastomosis Technique.

BACKGROUND: Anastomosis complications after esophagectomy are related to postoperative survival and quality of life. This is a retrospective observational study to identify risk factors for anastomotic stricture after esophageal cancer surgery and the effect of different anastomosis techniques on stricture development. METHODS: This study included 737 patients who underwent esophagectomy for esophageal cancer that used stomach conduits. Four types of anastomoses were used: manual sewing (n = 221, 30%), circular stapling (n = 172, 23%), hybrid linear stapling with a 45-mm stapler (HLS; n = 155, 21%), and triangular linear stapling with 60-mm staplers (TLS; n = 189, 26%). Multivariate analysis was performed to evaluate the risk factors for stricture. RESULTS: Strictures that required endoscopic dilatation within 1 year after surgery occurred in 105 patients (14%), and 13% of the strictures were related to leakage. Multivariate analysis revealed that chronic obstructive pulmonary disease (hazard ratio [HR] 1.726, P = .017), leakage (HR 2.502, P = .015), and anastomosis techniques other than TLS (manual sewing: HR 9.588; circular stapling: HR 6.516; HLS HR 5.462, all P < .001) were significant risk factors for stricture. TLS significantly reduced the stricture rate (3.2%) compared with other techniques (manual sewing: 22.2%; circular stapling:, 14.5%; HLS: 16.1%; P < .001). Stricture rate was lower in the TLS group in patients without leakage (P < .001); however, the effect disappeared with leakage. CONCLUSIONS: Anastomosis stricture occurred in 14% of esophagectomy patients. Chronic obstructive pulmonary disease, leakage, and anastomosis technique are risk factors for stricture. A large anastomosis area with the TLS technique using 60-mm length linear staplers prevented stricture, especially when leakage was not observed.

Examination of colorectal cancer cases with metal allergy.

PURPOSE: To report our initiatives and treatment results for patients with colorectal cancer with metal allergy. METHODS: A total of 27 patients (2.6%) with a history of metal contact dermatitis were identified among 1027 patients who underwent curative resection of colorectal cancer from 2014 to 2020. The results of the patch test, perioperative results, and postoperative colonoscopy findings were also investigated. RESULTS: The patch test for metal allergens and staples was performed in 21 patients (77.8%), and 13 of them (61.9%) tested positive for at least one metal allergen. Ni (38.1%), Co (28.6%), and Pd (19.0%) showed higher positive rates than other metals, and 1 patient (4.8%) tested positive for staples. Stapled anastomosis/suturing was performed as planned in 15 of 27 patients. In 10 patients, the anastomosis method was changed from stapled to hand-sewn according to the no-patch test results (60%), positivity for multiple metals (20%), positivity for staples (10%), and surgeon's judgment (10%). No complications and abnormal colonoscopy findings were found to be associated with stapled anastomosis/suturing. CONCLUSION: The patch test is useful for selecting an optimal anastomosis method for patients with suspected metal allergy.

[Non-surgical treatment of staple-line suture leakage after redo sleeve gastrectomy]. / Endoskopicheskoe klipirovanie nesostoyatel'nosti linii steplernogo shva posle povtornoi prodol'noi rezektsii zheludka.

Redo bariatric procedures are common. However, redo sleeve gastrectomy is not a frequent case of repeated bariatric surgery and can be performed rather as a necessary measure in difficult intraoperative conditions. We report a patient who underwent laparoscopic adjustable gastric band placement, its blockage and surgical removal, sleeve gastrectomy and redo sleeve gastrectomy. After that, staple-line suture failure developed that required endoscopic clipping.

Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: Double-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA. METHODS: The medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups. RESULTS: The high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa. CONCLUSIONS: In DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.

The Effect of Different Staple Sizes on Leak Pressure Among Patients Undergoing Sleeve Gastrectomy: a Pilot Study.

Gastric leak after LSG is a devastating complication, reported in less than 1% of cases. Consensus is lacking regarding the best approach to construct the sleeve, staple sizes, and reinforcement methods on potential leak development. In this study, we have compared the leak pressure of two different staple sizes in the resected portion of the stomach, immediately after its removal. Fifteen patients were enrolled. Leak pressure of a vascular, small-size stapler was significantly higher than that of a medium-size one. All leaks appeared in the proximal third of the resected stomach. These results may have clinical implication. Since other factors may play a role in the risk for leaks following sleeve gastrectomy, a large, prospective clinical trial should be performed comparing the two staple sizes in laparoscopic sleeve gastrectomy.

Surgical management of rectovaginal fistula after stapled transanal rectal resection for prolapsed hemorrhoids.

INTRODUCTION AND HYPOTHESIS: Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion. METHODS: A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion RESULTS: No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence. CONCLUSIONS: The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis.

BACKGROUND: Multiple linear stapler firings during double stapling technique (DST) after laparoscopic low anterior resection (LAR) are associated with an increased risk of anastomotic leakage (AL). However, it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis. AIM: To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging (MRI). METHODS: We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis, which were randomly divided into a training set (n = 260) and testing set (n = 68). Binary logistic regression was adopted to create a clinical model using six factors. The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed. Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks. Sensitivity, specificity, accuracy, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) was calculated for each model. RESULTS: The prevalence of ≥ 3 linear stapler cartridges was 17.7% (58/328). The prevalence of AL was statistically significantly higher in patients with ≥ 3 cartridges compared to those with ≤ 2 cartridges (25.0% vs 11.8%, P = 0.018). Preoperative carcinoembryonic antigen level > 5 ng/mL (OR = 2.11, 95%CI 1.08-4.12, P = 0.028) and tumor size ≥ 5 cm (OR = 3.57, 95%CI 1.61-7.89, P = 0.002) were recognized as independent risk factors for use of ≥ 3 linear stapler cartridges. Diagnostic performance was better with the integrated model (accuracy = 94.1%, PPV = 87.5%, and AUC = 0.88) compared with the clinical model (accuracy = 86.7%, PPV = 38.9%, and AUC = 0.72) and the image model (accuracy = 91.2%, PPV = 83.3%, and AUC = 0.81). CONCLUSION: MRI-based deep learning model can predict the use of ≥ 3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery. This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for ≥ 3 linear stapler cartridges.