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 movements [16]. 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 LSG [18]. 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 hospital [13]. Other researchers also reported comparable findings in terms of the clinical performance of powered staplers [15].

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 strengthening [25]. 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 [19, 20]. For example, in a propensity score-matched study, Shigeeda et al. reported that the use of powered staplers was associated with less fibrin glue consumption [20] (fibrin glue is a biological adhesive that is used for hemostasis).

In addition, the surgeons’ choice of the staplers also played an important role in interpreting the results. This study is a non-interventional study, therefore, surgeons would choose the staplers based on their preference and the difficulty of the surgical procedures. In general, surgeons tend to use GST staplers for patients with COPD, pleural adhesion, emphysema, or deep-seated tumor. Therefore, even if we controlled for baseline characteristics such as the complications and the complexity of pneumonectomy, the proportion of complicated surgical procedures was still higher in the GST group (not statistically significant), which confirmed the better clinical performance of the GST stapler and partially explained why there were no significant differences in some of the secondary outcomes such as the length of stay.

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.