Slow Stapler Firing May Reduce Intraoperative Staple-Line Air Leakage During Pulmonary Resection: A Retrospective Propensity Score-Matched Study

Background Air leakage after pulmonary resection is one of the most common complications in thoracic surgery and is associated with prolonged chest drainage and increased healthcare costs. Although linear staplers are widely used for pulmonary parenchymal division, the association between stapler firing speed and intraoperative air leakage during pulmonary parenchymal division remains unclear. Methods This retrospective single-center study included 232 patients who underwent pulmonary resection for non-small cell lung cancer between October 2023 and December 2025. Stapling procedures performed using conventional firing modes (approximately 6-10 seconds) were categorized as the fast mode, whereas procedures performed using the slow firing mode (≥20 seconds) were categorized as the slow mode. The primary endpoint was the presence of intraoperative air leakage originating from the staple line during the routine leak test. Surgical videos were retrospectively reviewed to identify staple-line-related air leaks. To adjust for baseline differences between groups, propensity score matching was performed using age, sex, Brinkman index, Goddard score, surgical approach, type of resection, reinforcement material use, and the number of stapler cartridges. Results Among the 232 patients, 147 were assigned to the fast mode group and 85 to the slow mode group. After propensity score matching, 83 matched pairs were analyzed. The incidence of staple-line air leak was lower in the slow mode group than in the fast mode group (n=9 (10.8%) vs. n=19 (22.9%); p=0.036). In univariable analysis, smoking history, Goddard score, and stapling speed were associated with air leakage. In multivariable logistic regression analysis, fast stapler firing (reference: slow firing) was significantly associated with intraoperative staple-line air leakage (OR 3.19; 95% CI: 1.1-6.2; p=0.03). Conclusions Although limited by device heterogeneity and its retrospective design, this study suggests that slower stapler firing may be associated with reduced intraoperative staple-line air leakage. These findings should be considered hypothesis-generating because complete separation of firing-speed effects from device-related factors was not feasible.