Stapler versus manual closure for pharyngeal repair after total laryngectomy: a systematic review and meta-analysis

Pharyngeal closure is a critical step in total laryngectomy influencing postoperative recovery. While manual suturing is traditional, stapler-assisted closure offers potential advantages. This study provides an updated meta-analysis comparing stapler versus manual closure, stratifying by surgical indication, laryngectomy type and stapler technique.

Following PRISMA guidelines, a systematic search of four databases, up to November 2025, was conducted. Randomized controlled trials (RCTs) and observational studies comparing stapler versus manual closure in total laryngectomy were included. The primary outcome was pharyngocutaneous fistula (PCF) incidence. Secondary outcomes mainly included operative time and hospital stay. Risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated using a random-effects model.

Twenty studies (4 RCTs, 16 observational) involving 1,545 patients were included. Stapler closure was associated with a significantly lower risk of PCF (RR = 0.54, 95% CI [0.38, 0.76], p < 0.001), shorter operative time (MD = -52.60, 95% CI [-74.33, -30.86], p < 0.001), and reduced hospital stay (MD = -3.62, 95% CI [-5.49, -1.76], p < 0.001). Subgroup analysis demonstrated a significant PCF reduction in primary laryngectomy (RR = 0.40, 95% CI [0.24, 0.69], p > 0.001), but this benefit was not statistically significant in salvage laryngectomy alone. Closed and semi-closed stapler techniques showed the most significant protective effects.

Stapler-assisted pharyngeal closure significantly reduces PCF incidence, operative time, and hospitalization compared to manual suturing in primary laryngectomy. While efficient, its superiority in preventing PCF in high-risk salvage settings is not established, warranting careful patient selection.