Key messages
• There is likely little or no difference in leaks from the pancreas (pancreatic fistula) and may be little or no difference in deaths after surgery, whether the pancreas is closed with a stapler or sewn by hand.
• Surgeons may choose the method they are more comfortable with or that best suits the patient’s situation.
• More research should focus on other ways to prevent leaks after pancreas surgery, as the best method is still not known.
What is the pancreas, and why is it removed?
The pancreas is an organ in the belly that helps with digestion and controls blood sugar. Sometimes, the end part of the pancreas (called the 'tail') has to be removed, for example because of a tumour. This operation is called a distal pancreatectomy.
One common problem after this surgery is a pancreatic fistula, which is when digestive juices leak from the cut end of the pancreas into the belly. This can cause pain, infections, and bleeding. Closing the pancreas properly after surgery is important to reduce this risk.
How is the pancreas closed after surgery?
There are two main ways to close the pancreas after the tail is removed:
• handsewn closure: the surgeon cuts the pancreas with a knife and sews it closed by hand;
• stapler closure: a device is used to cut and seal the pancreas in one step.
It is unclear which method is better for preventing problems after surgery.
What did we want to find out?
We wanted to know if stapler closure or handsewn closure works better to:
• reduce the number of leaks (pancreatic fistulas);
• lower the chance of dying after the operation;
• reduce other complications.
What did we do?
We looked for studies that compared stapler closure and handsewn closure in people who had surgery to remove the tail of the pancreas. We summarised the findings and judged how confident we are in the results.
What did we find?
We found three high-quality studies with 515 adults who had surgery to remove the tail of their pancreas. These studies took place in different countries and included people with various pancreas diseases.
There was likely little or no difference between the stapler and handsewn groups in how often a leak happened after surgery and other problems after surgery, and may be little or no difference in how many people died after the operation.
What are the limitations of the evidence?
The studies were not very large, and a few details were not reported clearly. Also, there were problems with the study methods that could have affected our conclusions. Because of this, we are not certain of the results. More research should explore other ways to prevent pancreatic fistula.
How up-to-date is this evidence?
The evidence is current to October 2023.
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.
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.
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.
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.
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).
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.
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.