S221 Stapled vs Hand-Sewn Anastomosis in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Introduction: The optimal anastomotic method for pancreaticoduodenectomy remains a subject of debate. This meta-analysis aimed to assess the postoperative outcomes of stapled anastomosis (SA) vs hand-sewn anastomosis of gastro/duodenojejunostomy in pancreaticoduodenectomy. Methods: Electronic databases including PubMed, Cochrane Library and ScienceDirect were searched from inception till January 2025. This review adhered closely to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The risk ratios (RR) along with the 95% confidence intervals (CI) were pooled under the random effects model using the review manager version 5.4.1 for the dichotomous outcomes. The primary and secondary endpoints of interest were clinically relevant delayed gastric emptying, anastomotic bleeding, anastomotic leakage, intra-abdominal abscess, mortality, and postoperative pancreatic fistula. The quality assessment was done through the Cochrane risk of bias 2.0 tool and the Newcastle Ottawa Scale. Publication bias was assessed visually through the funnel plots and statistically through Egger’s regression test. A leave-one-out sensitivity analysis was conducted to explore the source of heterogeneity. Results: Nine studies encompassing a total of 1,738 patients were included in this meta-analysis. SA group showed a significant increase in the risk of anastomotic bleeding (RR = 7.39, 95% CI: [2.20, 24.81]; P = 0.001; I2 = 0%). SA was associated with a low risk of clinically relevant delayed gastric emptying but the results were statistically non-significant (RR = 0.64; 95% CI: [0.38, 1.07]; P = 0.09; I2 = 75%). Similarly, other outcomes including the anastomotic leak (RR = 0.74; 95% CI: [0.27, 2.03]; P = 0.56; I2 = 0%), intra-abdominal abscess (RR = 1.36; 95% CI: [0.83, 2.24]; P = 0.22; I2 = 33%), postoperative pancreatic fistula (RR = 1.02; 95% CI: [0.84, 1.25]; P = 0.82; I2 = 0%) and mortality (RR = 2.45; 95% CI: [0.36, 16.83]; P = 0.36; I2 = 12%) were comparable between the 2 anastomotic techniques. Conclusion: SA significantly increases the risk of anastomotic bleeding compared to hand-sewn anastomosis in pancreaticoduodenectomy, while other postoperative outcomes, including DGE, anastomotic leakage, and mortality, remain comparable. These results highlight the need for cautious patient selection and careful surgical planning when opting for SA methods. Further studies are warranted to optimize stapling techniques and better define their role in clinical practice.