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Review
. 2025 Jun 10;6(6):CD008688.
doi: 10.1002/14651858.CD008688.pub3.

Stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy

Pascal Probst  1 , Felix J Hüttner  2 , Ulla Klaiber  3 , Phillip Knebel  4 , Alexis Ulrich  5 , Markus W Büchler  6 , Markus K Diener  2
Affiliations
Review

Stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy

Pascal Probst et al. Cochrane Database Syst Rev. .

Abstract

Background: Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, and is associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by handsewn closure of the pancreatic remnant and stapler resection and closure.

Objectives: To assess the effects of stapler resection and closure compared to scalpel resection followed by handsewn closure of the pancreatic remnant in people undergoing distal pancreatectomy.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from database inception to October 2023, and the ISGPS Evidence Map of Pancreatic Surgery to 9 April 2025.

Selection criteria: We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for open distal pancreatectomy (irrespective of language or publication status).

Data collection and analysis: Two review authors independently assessed trials for inclusion and performed data extraction. Our outcomes of interest were postoperative mortality and morbidity, especially postoperative pancreatic fistula. Taking into account the clinical heterogeneity between trials (e.g. different endpoint definitions), we analysed data using a random-effects model in RevMan, calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence.

Main results: In three trials, a total of 515 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 259) or scalpel resection followed by handsewn closure (n = 256). One study was a single-centre pilot RCT, and two studies were multicentre RCTs. The single-centre pilot RCT evaluated 69 participants in five intervention arms (stapler, handsewn, fibrin glue, mesh, and pancreaticojejunostomy), although we only assessed the stapler and handsewn closure groups (14 and 15 participants, respectively). The two multicentre RCTs had two interventional arms: stapler (n = 177 and 68) and handsewn closure (n = 175 and 66). Stapler may have similar effects on postoperative mortality compared to scalpel resection followed by handsewn closure, although the CI is wide (4 deaths per 1000 compared with 8 per 1000; RR 0.49, 95% CI 0.05 to 5.40; 3 RCTs; 515 participants; low-certainty evidence). Stapler likely results in little to no difference in postoperative pancreatic fistula according to the International Study Group of Pancreatic Surgery (ISGPS) definition compared to scalpel resection followed by handsewn closure (26% versus 29%; RR 1.11, 95% CI 0.84 to 1.47; 2 RCTs; 486 participants; moderate-certainty evidence). Stapler likely results in little to no difference in overall postoperative morbidity compared to scalpel resection followed by handsewn closure (63% versus 59%; RR 1.06, 95% CI 0.87 to 1.30; 2 RCTs; 486 participants; moderate-certainty evidence). We downgraded the certainty of evidence for all outcomes by one level due to potential selection bias alone or in combination with performance and detection bias, and for postoperative mortality by a further level for imprecision.

Authors' conclusions: The evidence is mainly based on the results of two multicentre RCTs. There is no ongoing RCT on this topic. We did not find evidence to indicate that either stapler or scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy is superior in terms of postoperative pancreatic fistula, overall postoperative mortality, or operation time. Currently, the choice of closure is left to the preference of the individual surgeon and the anatomical characteristics of the patient. Future trials stratifying for pancreatic texture (soft versus hard) could add valuable information to inform surgical approaches when considering different pancreatic textures. Future trials assessing novel methods of stump closure should compare them either with stapler or handsewn closure as a control group to ensure comparability of results.

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Conflict of interest statement

Although the trial with the largest sample size took place in our institution, this had no influence on our scientific judgement of the outcome of this systematic review. The Cochrane Upper Gastrointestinal and Pancreatic Diseases group identified an independent systematic reviewer (Yuhong Yuan) who extracted data for the Diener 2011 study.

PP: is a co‐founder of EVIglance Inc.; no other conflict of interest.

FH: is a co‐founder of EVIglance Inc.; no other conflict of interest.

UK: no conflict of interest

PK: no conflict of interest

AU: no conflict of interest

MWB: no conflict of interest

MKD: is a co‐founder of EVIglance Inc.; no other conflict of interest.

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References

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