To our best knowledge, it was the first real-world study in China that demonstrated the effect of the GST stapling system on the perioperative outcomes of segmentectomy and lobectomy procedures. Our findings suggested that the GST group was associated with better intraoperative outcomes, compared to the manual group. The risk for intraoperative bleeding and intraoperative interventions was significantly reduced using the GST system. Among all the secondary clinical outcomes, the use of GST system is associated with lower NEOVEIL consumption. The two groups did not differ significantly in terms of drainage tube duration and average operation time, which could be attributed to the relatively small sample size.
Since the study was conducted within a Chinese hospital context, the research interests may differ from that of the previous studies that were conducted within other countries. However, our study still contributes to the knowledge of the real-world effectiveness of the GST system. Our study results resonated with the previous findings that the GST system and powered staplers were clinically superior to manual staplers. Rawlins et al. reported that the GST system lowered the risk for developing hemostasis-related complications during the laparoscopic sleeve surgeries (LSG) compared to the Signia™ stapling system, as the GST system was more powerful in reducing tissue movements16. The reduced tissue movements were likely to be attributed to that the GST system powered staplers can effectively reduce surgeons’ unwanted hand movements due to the superiority of the physical characteristics of powered staplers. Additionally, Fegelmen et al. observed that the use of GST system was associated with significantly fewer staple line interventions during LSG18. Furthermore, as aforementioned, Miller et al. observed that the use of powered stapler was associated with a lower risk of having hemostasis-related complications during the surgery and the powered stapler can also reduce the total length of stay in hospital13. Other researchers also reported comparable findings in terms of the clinical performance of powered staplers15.
It is commonly acknowledged that perioperative complications can place a great burden on both physicians and patients and even sophisticated physicians cannot guarantee the absence of such undesired clinical outcomes. Surgical staplers were therefore invented to facilitate the procedure of anastomosis. Even though such devices have been proven to be helpful, perioperative complications still exist because of technical errors19. Hence, it is crucial to know about the technical challenges and understand why certain types of surgical staplers outperform others.
The very first challenge which is faced by surgeons is the physical characteristics of the surgical staplers. Physicians with smaller hands and weaker strength may experience more technical hardship when conducting operations, especially when they are operating manual staplers because manual staplers tend to be heavier than powered staplers20. A Japanese study revealed that the same surgical stapler can be rated significantly different by surgeons with different hand sizes and muscle strength20. One intuitive explanation is that lighter stapler devices are less stamina-consuming and are thus more favorable to surgeons. From the perspective of surgeon’s experience, powered staplers dominated over manual ones as Prachi et al reported that powered staplers lowered the firing force by 97% compared to manual staplers19.
Another thing that usually concerns physicians is the quality of the formation of staples. Using staples of the “right” height is the key to have a high-quality formation of staples. Staples that are too high cannot properly fixate the target tissue and may result in leakage or dehiscence alongside the staple line, while staples that are too short can place excessive pressure to the target tissue and may result in extra tissue trauma and frank necrosis21. Hence, it is essential for surgeons to measure the thickness of the target tissue before choosing the height of staples. Unfortunately, measuring the thickness of target tissue is a daunting task as it has no standard solution to it. The thickness of target tissue may vary depending on age, gender, organ structure, spot within the organ, and health conditions (disease status)21. In our study, the pulmonary tissue of patients with lung cancer is usually thick and thus can complicate the measuring process22. In addition, the tissue thickness can also be influenced by the compression force it takes. Given that the measuring process is taken under such compressive force, a very important question is under which compressive force we should measure the tissue thickness23. This question elaborates the difficulty of measuring tissue thickness because surgeons are not only confronted with the “fluid” nature of human tissues, but also needed to ponder the interactions between stapler devices and human tissues22. From this viewpoint, powered staplers still outperform manual staplers as the former ones replace manual effort by mechanical endeavors. In other words, it is more likely that the target tissue would be compressed into a consistent height by powered staplers and thus reduce staple malformation rate.
The GST-driven powered staplers (G-staplers) in particular are superior in each of the technological advantages aforementioned. The G-staplers are easier to operate within the port and the G-staplers can provide a consistent compressive force and gripping force at the same time via its cartridge to the target tissue, which can greatly reduce tissue slippage. In addition, the G-staplers adopt a double pressurization system. The GST system first performs precompression to the target tissue to squeeze the target tissue into a proper height and then compress the staples to into a B-shape within the tissue, which is thought to be the optimal shape24. The high success rate of the B-shape staple formation is due to the unsymmetric design of the GST staple, which is more compatible with the tissue flow. Hence, it was reasonable to observe better clinical outcomes in the GST group in our study.
Apart from the clinical performance, the powered staplers also consumed fewer medical materials compared to the manual staplers. NEOVEIL, made of polyglycolic acid, is a bioabsorbable mesh sheet that has been used for surgical suturing or tissue strengthening25. One thing to note is that a higher consumption of NEOVEIL usually indicates a high incidence of intraoperative complications. In our study, we observed that the GST group was associated with significantly fewer consumption of NEOVEIL. Our finding is consistent with few studies have focused on the consumption of surgical supplies. For example, in a propensity score-matched study, Shigeeda et al reported that the use of powered staplers was associated with less fibrin glue consumption26 (fibrin glue is a biological adhesive that is used for hemostasis).
This study has some limitations. One limitation is the absence of intraoperative leakage as a major outcome, given that no data were available on it and the study team cannot reliably recall the occurrence of this event. Secondly, The small sample size of this study prevent some comparisons from making statistical inference. In addition, given the nature of non-randomized study, we cannot randomize the stapler choice in the study design. Due to surgeons’ selection preference, there was a major selection bias for stapler choice in different surgical procedures and the study population was not representative as all the patients were from the single clinical site. For instance, surgeons chose to use GST power stapler in single port segmentectomy, and non-GST stapler in multi-port lobectomy. Owing to this selection of preference, we cannot compare the effectiveness of GST system between different procedures (i.e., single port segmentectomy vs multi-port lobectomy). Thus, the sample in this study had different surgical procedures (multi-port segmentectomy and single-port lobectomy). Ideally for this study, the effect of GST system would have been examined in comparable surgical procedures in order to eliminate the effect of surgeons’ difference/preference. Finally, information bias might occur due to the nature of retrospective study, although quality checks were implemented to reduce it. Moreover, a causal linkage could not be drawn between the use of GST system and better clinical outcomes as this study was an observational retrospective cohort study and so further prospective studies are needed.