Comparative Outcomes of CREATE Versus Conventional Double-Stapling Technique for Ultralow Rectal Cancer: A Multicenter Propensity-Matched Analysis

BACKGROUND: Distal rectal transection during laparoscopic ultralow anterior resection or intersphincteric resection is technically demanding and may affect internal anal sphincter preservation, contributing to low anterior resection syndrome. Conformal resection after eversion with asymmetric twice stapling was developed to refine distal transection and stapled coloanal anastomosis in ultralow rectal cancer. OBJECTIVE: To compare perioperative, functional, and oncological outcomes between CREATE and the conventional double-stapling technique in ultralow rectal cancer. DESIGN: Multicenter retrospective cohort study based on prospectively maintained databases, with comparative analysis using propensity score matching. SETTINGS: Three tertiary colorectal surgery centers in China. PATIENTS: Between 2012 and 2021, 448 eligible patients with ultralow rectal cancer underwent laparoscopic ultralow anterior resection or intersphincteric resection (conformal resection after eversion with asymmetric twice stapling, n = 80; double-stapling technique, n = 368). After propensity score matching, 168 patients were included (conformal resection after eversion with asymmetric twice stapling, n = 60; double-stapling technique, n = 108). MAIN OUTCOME MEASURES: Operative variables, anastomotic leakage, anastomosis height, low anterior resection syndrome scores at 6, 12, and 24 months after stoma reversal, and 3-year disease-free survival and overall survival. RESULTS: After matching, conformal resection after eversion with asymmetric twice stapling showed a higher anastomosis (3.0 vs 2.0 cm from the anal verge, p < 0.001), a shorter distal resection margin (1.0 vs 1.2 cm, p < 0.001), and a shorter operative time (153 vs 175 min, p = 0.04). Anastomotic leakage occurred more frequently in the double-stapling technique group (1.7 vs 6.5%), although the difference was not statistically significant (p = 0.31). Low anterior resection syndrome outcomes were more favorable with conformal resection after eversion with asymmetric twice stapling at 6 months (major 42.9 vs 72.5%, p = 0.01) and 12 months (35.3 vs 66.7%, p = 0.007), with no differences at 24 months (p = 1.00). Three-year disease-free survival (88.4 vs 86.1%, p = 0.94) and overall survival (89.3 vs 91.5%, p = 0.60) were comparable between groups. LIMITATIONS: Selective eligibility for conformal resection after eversion with asymmetric twice stapling and functional assessment limited to patients who underwent stoma reversal and completed low anterior resection syndrome evaluations. CONCLUSIONS: CREATE was associated with a higher anastomosis and faster early functional recovery without increasing perioperative risk or compromising 3-year oncological outcomes. See Video Abstract.