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Pitfalls in Use of Stapler in Gastrointestinal Tract Surgery
Complications of General Surgery
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Pitfalls in Use of Stapler in Gastrointestinal Tract Surgery
Patricia L. Roberts, MD, * Warren A. Williamson, MD, t and Laura B. Sanders, MD:j:
The method of stapling as a substitute for suturing in surgery of the gastrointestinal tract dates from 1908, when the Hungarian surgeon Hiiltl19 introduced a mechanical stapler. Although it was too slow and awkward to achieve widespread acceptance, the stapler was used to provide two double rows of fine steel wire staples with a B-shaped configuration when closed, all of which are features of modern staplers. 34 Staplers developed in the Soviet Union in the 1950s for vascular, pulmonary, and gastrointestinal tract procedures gradually became popular in the United States. 34 Staplers made in the US today are easier to use and have become widely popular, especially for use in gastrointestinal tract surgery.
GENERAL PRINCIPLES
When properly used, staplers produce anastomoses comparable in reliability to hand-sewn ones, and some staplers, especially the end-to-end anastomosis (EEA) stapler, have different strengths. The concept of stapling should call to the surgeon's attention potential difficult points in application. The internal stapler joins two visceral walls with a fine wire staple that, when driven against an anvil, closes into a B-shaped configuration. Small vessels within the loop of the B remain open to create the advantage of leaving viable tissue beyond the B and the disadvantage of not being hemostatic. The length of the legs of the staple (most staples are available *StaIf, Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts; and Assistant Clinical Professor of Surgery, Boston University School of Medicine, Boston, Massachusetts tStaIf, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts; and Clinical Instructor in Surgery, Harvard Medical School, Boston, Massachusetts *StaIf, Department of General Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts .
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in more than one size) determines the thickness of the tissues when squeezed in their final form. 7, 35 Basic rules of sound surgical technique apply to stapled as well as to sutured anastomoses, An anastomosis that is insecure when sewn cannot be rescued by an expensive mechanical device, Adequate blood supply (manifested in stapled anastomoses by some oozing at the edge beyond the staples), absence of sepsis, freedom from tension, and adequately cleared serosal surfaces are necessary for proper healing of any type of anastomosis. In fact, because the staple wire is so fine and, at least in theory, prone to tear through tissue, absence of tension is probably more important in a stapled anastomosis than in a sutured anastomosis. Manipulation of a stapled anastomosis (i. e., in reducing a stapled ileostomy closure through the fascia back into the abdomen or in reducing a stapled small-bowel anastomosis through a small opening after resection for a strangulated hernia) should be accomplished with respect for the delicacy of the tissues involved. 7 A number of studies6 , 7, 9, 17, 21, 22, 24, 31 reported complication rates associated with stapled versus sutured anastomoses, but no appreciable differences emerged. Most of these studies demonstrated an acceptable although constant rate of leakage; however, one study17 suggested that the success of any technique is dependent on the skill of the operator. A British study24 found that, although the rate of breakdown of sutured anastomoses was the same for registrars (less experienced) and consultants (more experienced), the staplers were much less reliable when used by younger surgeons. Similarly, one large series 23 of esophagogastrectomies reported no leakage at all when a standardized two-layer hand-sewn anastomosis was used, which led to the conclusion that when properly used, sewn anastomoses are superior to stapled anastomoses. The EEA stapler uses a ring of staples of fixed size, which creates the additional risk of stricture in esophageal or rectal surgery. The largest staple available that will not tear the viscus should be used. Bleeding from the edge of the anastomosis, mentioned earlier, is a particularly high risk associated with use of staples because the closure is not hemostatic.1 4 When an anastomosis is created, it should be checked carefully inside and outside, and bleeding points should be controlled with sutures or the electrocautery. The operative site should be checked for the presence of intramural hematomas, which might predispose to anastomotic disruption or sepsis, before the abdomen is closed. The size of the stapler should be chosen with thought given to the thickness of tissue involved. Most linear staplers, such as the gastrointestinal anastomosis (CIA) stapler, which staples and cuts, or the thoracoabdominal anastomosis (TA) stapler (United States Surgical Corp., Norwalk, CT), which only staples, come in two lengths of staples. 21 Most of the large and small bowel, for instance, is stapled with 3,5- to 4,5-mm staples that close to a height of 1.2 mm and are usually marked by manufacturers with a blue label. For use with thicker tissue, such as gastric wall,31 there are the 4,8to 5.5-mm staples, which close to a height of 1.6 to 1. 7 mm and come with a green label from most manufacturers, Use of too small a stapler or, conversely, use of too large a stapler on thinner tissue leads to the risk of
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leakage. When tissues of different thicknesses are stapled, such as for gastroenterostomy, the larger staples can be used; however, some surgeons 31 prefer to suture or at least to reinforce with suture an anastomosis between viscera of different thicknesses because of reports of higher rates of leakage in these anastomoses. The suture closure is adjustable, whereas the staple closure is standardized. A problem occurs in closure of the duodenal stump in the performance of gastrectomy. The duodenal stump, especially when thickened or made brittle by ulcer disease, or when it must be freed to apply the stapler, is especially vulnerable to tearing or fracture when stapled. Although it is not yet well documented, some surgeons believe that the stapled duodenal stump is less secure than the sewn one. The potential for leakage at the duodenal stump probably outweighs any convenience gained by stapling the stump closed. Time saved and money expended are other much-discussed stapling topics. It seems obvious and is often claimed that use of staplers saves operating time. 6.7.34,35 However, studies5, 8, 32 that have compared the actual time of operation have found the times remarkably similar for each technique. The initial cost of a stapler is another drawback to its use, although this drawback must be weighed against the cost of the suture the stapler replaces. Allergic or other reaction to the material used for stapling is another, although rare, drawback to its use. Formation of calculi after construction of a urinary tract conduit with staples,4 dermatitis caused by nickel allergy when using the skin stapler,29 and chronic urticaria from tantalum staples 36 have been reported. TYPES OF ANASTOMOSES Esophagogastric Anastomosis Androsov1 in 1970 first reported the availability of a mechanical stapling device capable of end-to-end anastomosis between the esophagus and small bowel, stomach, and colon. Since development of this early prototype, two stapling devices, the EEA stapler (United States Surgical Corp.) and the intraluminal stapler (Ethicon, Inc., Somerville, NJ) have come into widespread clinical use. Considerable experience has been gained with use of these instruments in esophagogastric anastomosis with distal esophageal resection through a left thoracotomy, with middle-third esophageal resection using the Ivor-Lewis approach, and with substernal gastric bypass and cervical esophagogastric anastomosis. 3, 10-12, 18, 25-27. 33, 37, 38 Despite the technical ease with which these anastomoses can be performed with circular stapling instruments, the complications of leakage and stricture have not been eliminated. The incidence of anastomotic leakage has been documented as 0 to 5% in various studies. 33, 38 However, routine contrast studies of the esophagus were not performed in many of these reports, and, therefore, these reports may underestimate the true incidence of leakage. Clinical evidence of formation of a stricture has been reported2, 10-12, 18,25-27,33,37,38 in 10% to 15.4% of patients. These complications
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can be minimized by adhering to the general principles of preserving adequate blood supply to the stomach and esophagus, avoiding tension on the anastomosis, and providing adequate decompression and adequate nutritional support to the patient. In addition, precise mucosa-to-mucosa apposition is important to reduce the incidence of leakage and benign anastomotic stricture in these patients. Furthermore, specific pitfalls inher~ ent in anastomotic construction with the stapling device should be avoided to reduce the incidence of leakage and stricture. One of the most common causes of an inadequate mucosa-to-mucosa approximation is tearing the esophageal mucosa with an oversized stapling cartridge. The stapling cartridge should easily pass into the proximal esophagus without tension on the mucosa. With a noncompliant proximal esophagus, the stapling head should be of a smaller size. When a tear of the mucosa occurs during introduction of the stapling cartridge, it is wise to resect a larger cuff of proximal esophagus beyond the point of injury to the muscularis, because the mucosal tear often extends more proximally than the muscular tear. Use of a smaller stapling cartridge prevents this complication. Another cause of leakage at the stapled esophagogastric anastomosis is an inadequate proximal esophageal pursestring suture. This suture must adequately cinch the esophageal mucosa and muscularis around the central shaft of the stapling device. To avoid gaps in the purse string suture line, a continuous 0 or 2-0 polypropylene (Prolene) suture is placed meticulously through both mucosa and muscular layers of the esophagus 2 to 3 mm from the cut edge, and enough bites, usually six to eight circumferentially, are taken to avoid gaps and puckering. Molina and colleagues25 described a technique for placement of the proximal pursestring suture that prevented retraction of the esophageal mucosa. They opened the anterior wall of the esophagus, started the pursestring suture around the anterior wall, detached the posterior wall of the esophagus, and continued the purse string suture circumferentially as they cut. To avoid retraction of the mucosa on the gastric side of the anastomosis, the smallest hole that will permit passage of the central shaft is made. Too large a hole will permit retraction of the gastric mucosa. When the stapling cartridge has been fired, gentle traction is applied on the instrument while supporting the anastomosis and withdrawing the instrument. The resulting rings of tissue are always examined to confirm the presence of two intact "doughnuts" of tissue from the gastric and esophageal ends. A defect in the continuity of these circular rings of tissue implies a lack of integrity of the anastomosis. The area in question should be reinforced with interrupted sutures, and consideration should be given to wrapping the area with omentum or a partial wrap with the stomach. Some authors 12, 38 advocate routine wrapping of these anastomoses, but most surgeons find this procedure unnecessary. The site of gastrotomy through which the stapling instrument was introduced should also be closed carefully because some reports 26, 37 have identified this suture line as a source of leakage. We routinely oversew all stapled gastric suture lines when the stomach is brought up into the chest. In addition, spacing of the gastrotomy and anastomotic site at least 2 to 3
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cm from the staple line in the gastric remnant helps to reduce the possibility of vascular compromise and resulting leakage. Various techniques for testing the anastomosis, including insufflation with air or saline solution, have been advocated, 18. 37 but such maneuvers are not necessary. With stapled anastomoses, anastomotic narrowing with formation of a stricture is a more common complication than leakage. In a large series reported by Muehrcke and coworkers,27 the incidence of benign stricture after esophagogastrectomy and end-to-end anastomosis with the circular stapling instrument was 12.5%. An inverse relationship appeared to exist between the incidence of benign stricture and the size of the stapling head, although these differences did not reach statistical significance. The incidence of stricture with the 31-mm stapling cartridge was 5.4%, 13.5% with the 28-mm stapling cartridge, and 17% with the 25-mm stapling cartridge. These figures suggest, and it usually follows, that a smaller anastomosis is more prone to the development of a stricture than a larger anastomosis, but the sample size was too small to prove this theory. The inclination to use the largest stapling head to avoid the complication of stricture should be offset by the more serious problem of mucosal tearing caused by an oversized stapling head and the potential lethal complication of leakage. For the most part, a benign esophageal anastomotic stricture that occurs after either a stapled or a hand-sewn anastomosis is easily managed with dilation and does not require further surgical intervention. 1. 18. 27 In summary, adherence to these technical points can minimize the potential complications associated with stapled esophagogastric anastomoses. End-to-End Anastomosis Since the introduction of the EEA stapler for rectal reconstruction, the technique has been modified so that the lower rectal segment is closed with a linear stapler (TA), and the anastomosis is performed using the EEA stapler across the linear staple line (combined or double-staple technique). 20 This double-staple technique obviates the difficulty associated with application of a pursestring suture on the lower rectal segment deep in the pelvis. Although theoretical concerns exist about the potential complications associated with intersecting staple lines, no problem has materialized clinically.28 Nevertheless, although the double-staple technique has enjoyed widespread popularity, it is important to pay meticulous attention to detail to avoid intraoperative pitfalls that may have immediate and long-term implications. The technique of low anterior resection and reconstruction by use of the stapler has been aided by recent modifications in the TA-55 (Roticulator 55; United States Surgical Corp.) and circular stapling devices (Premium CEEA; United States Surgical Corp.). In this procedure, a roticulating TA55 stapler is placed at the distal margin of resection. This instrument is particularly suited to placement low in the pelvis; the angle of the head can be altered to facilitate placement and to avoid the symphysis pubis. The instrument is fired after the surgeon has ascertained that no extraneous tissue is incorporated in the stapler. The specimen is transected proximal to the staple line. The perineal operator distends the rectal segment with
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povidone-iodine (Betadine) solution or saline solution. Any leakage from the staple line is easier to repair at this point than after the anastomosis has been completed. The colon is transected proximally. A pursestring suture is placed around the proximal end, and sizers are used to determine the size of the circular stapling instrument to be used. The appropriate Premium CEEA stapler with its centerpost and anvil removed is placed in the proximal bowel and secured with a whip stitch suture. Placement of the pursestring suture before use of the sizers prevents serosal splitting of the bowel. The trocar is withdrawn into the staple cartridge, and the instrument is introduced transanally to the top of the rectal pouch. Improper introduction of the stapler may in rare instances result in perforation of the posterior rectal wall. The trocar and centerpost are advanced, and the trocar is brought through the bowel immediately adjacent to the staple line. It is important not to leave a rim of tissue between the staple line and the trocar that could become ischemic. The anvil is guided down to the trocar and secured, and the instrument is fired. The instrument is disengaged and slowly withdrawn with a gentle rotational movement. Although the instrument is usually withdrawn easily, many problems can develop. Difficulty Extracting the Stapler. Difficulty in extracting the EEA stapler through the rectum, one of the most common intraoperative problems encountered, may result, in part, because the internal diameter of the anastomosis is smaller than that of the EEA stapler. In addition, the cutting blade of the EEA stapler may not have completely incised the rings of tissue. Vigorous attempts at withdrawal of the EEA stapler may result in disruption of the anastomosis or tearing of the bowel wall. This problem is avoided by gently rocking the instrument and by making larger circles while the abdominal operator supports the rectum distal to the anastomosis. When this procedure is unsuccessful, Lembert sutures may be placed distal to the anastomosis to help hold up the anterior lip of the anastomosis and to facilitate extraction of the instrument. As a last resort, a proximal colotomy can be made and the anvil removed through this area. Thorough inspection of the anastomosis is mandatory, particularly when extraction of the stapler was difficult. Incomplete Rings of Tissue. After the stapler is withdrawn, the rings of tissue are examined to ensure that they are intact and incorporate all layers of the bowel wall. The orientation of the rings of tissue is maintained on the centerpost of the EEA stapler because they assist the surgeon in the detection of the precise site of deficiency. Incomplete rings of tissue may result from failure to incorporate all layers of the bowel into the pursestring suture and slipped knots after the pursestring suture is secured. The integrity of the anastomosis can be ensured by direct inspection, by irrigation of the rectum with saline or povidone-iodine solution, or by air insufflation of the rectum. Leakage at the suture line, when encountered, is managed by suture closure. Intraoperative testing of the anastomosis has been shown to decrease Significantly the number of leakages seen clinically and radiologically. 2
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Anastomotic Leakage. Anastomotic leakage is the most serious perioperative complication. To prevent this complication, it is prudent to test the anastomosis intraoperatively by instillation of povidone-iodine or saline solution or air to assess for leakage. The incidence of anastomotic leakage varies. When the results of 10 series of 1483 patients were pooled, the clinical rate of leakage was 4.4%.16 The incidence of leakage is increased in low rectal anastomoses and may be increased in patients who have inadequate bowel preparation, poor blood supply to both ends of the bowel, and tension on the anastomosis. However, the most important factor in the prevention of anastomotic leakage appears to be surgical technique. 13 Rectovaginal or Rectovesical Fistula. The formation of a rectovaginal or rectovesical fistula is rare after stapled anastomosis. A rectovaginal fistula may occur after inadvertent incorporation of a portion of the vagina into the end-to-end anastomosis. Such an occurrence is more likely in women who have undergone previous hysterectomy. In these patients, the rectovaginal septum may be scarred and adherent and difficult to separate. A rectovaginal fistula may also result from anastomotic leakage or abscess that drains through the point of least resistance. Most patients in whom a rectovaginal fistula develops require proximal fecal diversion. Hemorrhage. Postoperative hemorrhage is an uncommon complication with use of the EEA stapler; it is usually from the staple line and is selflimited. In the patient with ongoing bleeding, transanal endoscopic visualization of the anastomosis can be performed and the bleeding point coagulated or suture ligated. Anastomotic Stricture. Although a stricture may form at the site of any anastomosis, its formation appears to be more common with use of the EEA stapler. The cause of an anastomotic stricture is multifactorial; stapled anastomoses heal by secondary intention because the mucosa of the bowel is not apposed but is separated by the muscular and serosal layers. 30 Healing of a stapled anastomosis results in a perfectly circular scar. The formation of an anastomotic stricture may be related to tension and resultant ischemia or to anastomotic leakage that subsequently causes fibrosis and formation of granulation tissue. The incidence of stricture varies and is determined by the surgeon's definition of stricture and by the inclusion of asymptomatic strictures. Some evidence of stricture is found in most anastomoses initially; commonly, a standard-size rigid sigmoidoscope cannot be passed beyond an anastomosis in the first 2 to 3 months after operation. With repeated passage of stool through the anastomosis, gradual dilation ensues. The use of bulk agents can also aid in dilation of the stricture. Subsequently, in a small number of patients, a symptomatic stricture persists. Stricture occurs more frequently after use of the 25-mm cartridge compared with the 28mm or 31-mm cartridge. Use of the 25-mm cartridge should be avoided. A hand-sewn anastomosis or alternative procedure should be considered when a larger cartridge cannot be used. Stricture also occurs more commonly in patients who have had proximal fecal diversion. One series 15 found that transverse colostomy was associated with a 36% incidence of stenosis compared with an 8% incidence of stenosis overall. A symptomatic stricture that persists beyond 3 months should be
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Figure 1. A stricture occurring after a double-stapled end-to-end anastomosis is shown. Through a rigid sigmoidoscope, fragments of tissue in three or four areas of the anastomosis are excised by standard biopsy forceps, and the stricture is dilated. (Reprinted with permission of the Lahey Clinic, Burlington, MA.)
B. Correct Figure 2. A functional end-to-end anastomosis is shown. It is preferable to stagger the staple lines (X, Y). (Reprinted with permission of the Lahey Clinic, Burlington, MA.)
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treated, as should asymptomatic strictures that do not permit passage of a flexible sigmoidoscope or colonoscope, thus precluding examination of the more proximal bowel. Such an occurrence is uncommon. In a collected series 16 of almost 1500 patients, the incidence of symptomatic stricture was only 1. 7%. Patients with such strictures can be treated by dilation with a bougie or a sigmoidoscope after excision of scar tissue of the anastomosis in three or four areas with standard biopsy forceps (Fig. 1). The excised fragments of tissue should be submitted for pathologic examination to exclude recurrent carcinoma. Functional End-to-End Anastomosis The functional end-to-end anastomosis, which employs the CIA and TA staplers, can be created for ileocolostomy, colocolostomy, or colorectostomy. To perform such an anastomosis, the bowel is transected proximally and distally with a CIA stapler. The remaining ends of bowel are brought together in parallel fashion, and an enterotomy is made on either end along the antimesenteric surface. The CIA forks are placed, one down the proximal end and the other down the distal end, and the instrument is fired. The staple line is inspected, and bleeding is controlled by either electrocautery or suture ligation. The anastomosis is completed by a TA-55 stapler. It is helpful to stagger the staple lines slightly (Fig. 2). Before the TA-55 stapler is fired, Allis clamps are placed on the bowel with particular attention paid to the corners to ensure that they are included.
SUMMARY The development of stapling instruments has been an enormous advancement in surgery of the gastrointestinal tract. No instrument, however, can replace sound surgical judgment and technique.
REFERENCES 1. Androsov PI: Experience in the application of the instrumental mechanical suture in surgery of the stomach and rectum. Acta Chir Scand 136:57-63, 1970 2. Beard JD, Nicholson ML, Sayers RD, et al: Intraoperative air testing of colorectal anastomoses: A prospective, randomized trial. Br J Surg 77:1095-1097, 1990 3. Behl PR, Holden MP, Brown AH: Three years' experience with esophageal stapling device. Ann Surg 198:134-136, 1983 4. Brenner M, Johnson DE: Ileal conduit calculi from stapler anastomosis: A long-term complication? Urology 26:537-540, 1985 5. Cajozzo M, Compagno G, DiTora P, et al: Advantages and disadvantages of mechanical versus manual anastomosis in colorectal surgery. Acta Chir Scand 156:167-169, 1990 6. Chassin JL, Rifkind KM, Sussman B, et al: The stapled gastrointestinal tract anastomosis: Incidence of postoperative complications compared with the sutured anastomosis. Ann Surg 188:689-696, 1978
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7. Chassin JL, Rifkind KM, Turner JW: Errors and pitfalls in stapling gastrointestinal tract anastomoses. Surg Clin North Am 64:441-459, 1984 8. Didolkar MS, Reed WP, Elias EG, et al: A prospective randomized study of sutured versus stapled bowel anastomoses in patients with cancer. Cancer 57:456-460, 1986 9. Di Matteo G, Cancrini A Jr, Palazzini G, et al: Stapled suture in digestive tract surgery. Int Surg 73:23-28, 1988 10. Donnelly RJ, Sastry MR, Wright CD: Oesophagogastrectomy using the end to end anastomotic stapler: Results of the first 100 patients. Thorax 40:958-959, 1985 11. Dorsey JS, Esses S, Goldberg M, et al: Esophagogastrectomy using the auto suture EEA surgical stapling instrument. Ann Thorac Surg 30:308-312, 1980 12. Fekete F, Breil P, Ronsse H, et al: EEA stapler and omental graft in esophagogastrectomy: Experience with 30 intrathoracic anastomoses for cancer. Ann Surg 193:825-830, 1981 13. Fielding LP, Stewart-Brown S, Blesovsky L, et al: Anastomotic integrity after operations for large-bowel cancer: A multicentre study. Br Med J 281:411-414, 1980 14. Fischer MG: Bleeding from stapler anastomosis. Am J Surg 131:745-747, 1976 15. Graffner H, Fredlund P, Olsson SA, et al: Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument: A randomized study. Dis Colon Rectum 26:87-90, 1983 16. Griffen FD, Knight CD, Whitaker JM, et al: The double stapling technique for low anterior resection: Results, modifications, and observations. Ann Surg 211:745-752, 1990 17. Hedberg SE, Helmy AH: Experience with gastrointestinal stapling at the Massachusetts General Hospital. Surg Clin North Am 64:511-528, 1984 18. Hopkins RA, Alexander JC, Postlethwait RW: Stapled esophagogastric anastomosis. Am J Surg 147:283-287, 1984 19. Hiilt! H: Cited in Surgical Stapling Techniques. Somerville, NJ, Ethicon, 1986 20. Knight CD, Griffen FD: An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 88:710-714, 1980 21. Latimer RG, Doane W A, McKittrick JE, et al: Automatic staple suturing for gastrointestinal surgery. Am J Surg 130:766-771, 1975 22. Lowdon IMR, Gear MWL, Kilby JO: Stapling instruments in upper gastrointestinal surgery: A retrospective study of 362 cases. Br J Surg 69:333-335, 1982 23. Mathisen DJ, Grillo HC, Wilkins EW Jr, et al: Transthoracic esophagectomy: A safe approach to carcinoma of the esophagus. Ann Thorac Surg 45:137-143, 1988 24. McManus KG, Ritchie AJ, McGuigan J, et al: Sutures, staplers, leaks and strictures: A review of anastomoses in oesophageal resection at Royal Victoria Hospital, Belfast 19771986. Eur J Cardio-thorac Surg 4:97-100, 1990 25. Molina JE, Lawton BR, Avance D: Use of circumferential stapler in reconstructions following resection for carcinoma of the cardia. Ann Thorac Surg 31:325-328, 1981 26. Muehrcke DD, Donnelly RJ: Complications after esophagogastrectomy using stapling instruments. Ann Thorac Surg 48:257-262, 1989 27. Muehrcke DD, Kaplan DK, Donnelly RJ: Anastomotic narrowing after esophagogastrectomy with the EEA stapling device. J Thorac Cardiovasc Surg 97:434-438, 1989 28. Nance FC: New techniques of gastrointestinal anastomoses with the EEA stapler. Ann Surg 189:587-600, 1979 29. Oakley AMM, Ive FA, Carr MM: Skin clips are contraindicated when there is nickel allergy. J R Soc Med 80:290-291, 1987 30. Penninckx FM, Kerremans RP, Geboes KJ: The healing of single- and double-row stapled circular anastomoses. Dis Colon Rectum 27:714-719, 1984 31. Reiling RB, Reiling W A Jr, Bernie W A, et al: Prospective controlled study of gastrointestinal stapled anastomoses. Am J Surg 139:147-152, 1980 32. Seufert RM, Schmidt-Matthiesen A, Beyer A: Total gastrectomy and oesophagojejunostomy: A prospective randomized trial of hand-sutured versus mechanically stapled anastomoses. Br J Surg 77:50-52, 1990 33. Shahinian TK, Bowen JR, Soderberg CH Jr, et al: Experience with the EEA stapling device. Am J Surg 139:549-553, 1980 34. Surgical Stapling Techniques. Somerville, NJ, Ethicon, 1986
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35. Tuchmann A, Dinstl K, Strasser K, et al: Stapling devices in gastrointestinal surgery. Int Surg 70:23-27, 1985 36. Werman BS, Rietschel RL: Chronic urticaria from tantalum staples. Arch Dermatol 117:438-439, 1981 37. West PN, Marbarger JP, Martz MN, et al: Esophagogastrectomy with the EEA stapler. Ann Surg 193:76-81, 1981 38. Wong J, Cheung H, Lui R, et al: Esophagogastric anastomosis performed with a stapler: The occurrence of leakage and stricture. Surgery 101:408-415, 1987
Address reprint requests to Patricia L. Roberts, MD Department of Colon and Rectal Surgery Lahey Clinic Medical Center 41 Mall Road Burlington, MA 01805
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Pitfalls in Use of Stapler in Gastrointestinal Tract Surgery
Patricia L. Roberts, MD, * Warren A. Williamson, MD, t and Laura B. Sanders, MD:j:
The method of stapling as a substitute for suturing in surgery of the gastrointestinal tract dates from 1908, when the Hungarian surgeon Hiiltl19 introduced a mechanical stapler. Although it was too slow and awkward to achieve widespread acceptance, the stapler was used to provide two double rows of fine steel wire staples with a B-shaped configuration when closed, all of which are features of modern staplers. 34 Staplers developed in the Soviet Union in the 1950s for vascular, pulmonary, and gastrointestinal tract procedures gradually became popular in the United States. 34 Staplers made in the US today are easier to use and have become widely popular, especially for use in gastrointestinal tract surgery.
GENERAL PRINCIPLES
When properly used, staplers produce anastomoses comparable in reliability to hand-sewn ones, and some staplers, especially the end-to-end anastomosis (EEA) stapler, have different strengths. The concept of stapling should call to the surgeon's attention potential difficult points in application. The internal stapler joins two visceral walls with a fine wire staple that, when driven against an anvil, closes into a B-shaped configuration. Small vessels within the loop of the B remain open to create the advantage of leaving viable tissue beyond the B and the disadvantage of not being hemostatic. The length of the legs of the staple (most staples are available *StaIf, Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts; and Assistant Clinical Professor of Surgery, Boston University School of Medicine, Boston, Massachusetts tStaIf, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts; and Clinical Instructor in Surgery, Harvard Medical School, Boston, Massachusetts *StaIf, Department of General Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts .
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in more than one size) determines the thickness of the tissues when squeezed in their final form. 7, 35 Basic rules of sound surgical technique apply to stapled as well as to sutured anastomoses, An anastomosis that is insecure when sewn cannot be rescued by an expensive mechanical device, Adequate blood supply (manifested in stapled anastomoses by some oozing at the edge beyond the staples), absence of sepsis, freedom from tension, and adequately cleared serosal surfaces are necessary for proper healing of any type of anastomosis. In fact, because the staple wire is so fine and, at least in theory, prone to tear through tissue, absence of tension is probably more important in a stapled anastomosis than in a sutured anastomosis. Manipulation of a stapled anastomosis (i. e., in reducing a stapled ileostomy closure through the fascia back into the abdomen or in reducing a stapled small-bowel anastomosis through a small opening after resection for a strangulated hernia) should be accomplished with respect for the delicacy of the tissues involved. 7 A number of studies6 , 7, 9, 17, 21, 22, 24, 31 reported complication rates associated with stapled versus sutured anastomoses, but no appreciable differences emerged. Most of these studies demonstrated an acceptable although constant rate of leakage; however, one study17 suggested that the success of any technique is dependent on the skill of the operator. A British study24 found that, although the rate of breakdown of sutured anastomoses was the same for registrars (less experienced) and consultants (more experienced), the staplers were much less reliable when used by younger surgeons. Similarly, one large series 23 of esophagogastrectomies reported no leakage at all when a standardized two-layer hand-sewn anastomosis was used, which led to the conclusion that when properly used, sewn anastomoses are superior to stapled anastomoses. The EEA stapler uses a ring of staples of fixed size, which creates the additional risk of stricture in esophageal or rectal surgery. The largest staple available that will not tear the viscus should be used. Bleeding from the edge of the anastomosis, mentioned earlier, is a particularly high risk associated with use of staples because the closure is not hemostatic.1 4 When an anastomosis is created, it should be checked carefully inside and outside, and bleeding points should be controlled with sutures or the electrocautery. The operative site should be checked for the presence of intramural hematomas, which might predispose to anastomotic disruption or sepsis, before the abdomen is closed. The size of the stapler should be chosen with thought given to the thickness of tissue involved. Most linear staplers, such as the gastrointestinal anastomosis (CIA) stapler, which staples and cuts, or the thoracoabdominal anastomosis (TA) stapler (United States Surgical Corp., Norwalk, CT), which only staples, come in two lengths of staples. 21 Most of the large and small bowel, for instance, is stapled with 3,5- to 4,5-mm staples that close to a height of 1.2 mm and are usually marked by manufacturers with a blue label. For use with thicker tissue, such as gastric wall,31 there are the 4,8to 5.5-mm staples, which close to a height of 1.6 to 1. 7 mm and come with a green label from most manufacturers, Use of too small a stapler or, conversely, use of too large a stapler on thinner tissue leads to the risk of
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leakage. When tissues of different thicknesses are stapled, such as for gastroenterostomy, the larger staples can be used; however, some surgeons 31 prefer to suture or at least to reinforce with suture an anastomosis between viscera of different thicknesses because of reports of higher rates of leakage in these anastomoses. The suture closure is adjustable, whereas the staple closure is standardized. A problem occurs in closure of the duodenal stump in the performance of gastrectomy. The duodenal stump, especially when thickened or made brittle by ulcer disease, or when it must be freed to apply the stapler, is especially vulnerable to tearing or fracture when stapled. Although it is not yet well documented, some surgeons believe that the stapled duodenal stump is less secure than the sewn one. The potential for leakage at the duodenal stump probably outweighs any convenience gained by stapling the stump closed. Time saved and money expended are other much-discussed stapling topics. It seems obvious and is often claimed that use of staplers saves operating time. 6.7.34,35 However, studies5, 8, 32 that have compared the actual time of operation have found the times remarkably similar for each technique. The initial cost of a stapler is another drawback to its use, although this drawback must be weighed against the cost of the suture the stapler replaces. Allergic or other reaction to the material used for stapling is another, although rare, drawback to its use. Formation of calculi after construction of a urinary tract conduit with staples,4 dermatitis caused by nickel allergy when using the skin stapler,29 and chronic urticaria from tantalum staples 36 have been reported. TYPES OF ANASTOMOSES Esophagogastric Anastomosis Androsov1 in 1970 first reported the availability of a mechanical stapling device capable of end-to-end anastomosis between the esophagus and small bowel, stomach, and colon. Since development of this early prototype, two stapling devices, the EEA stapler (United States Surgical Corp.) and the intraluminal stapler (Ethicon, Inc., Somerville, NJ) have come into widespread clinical use. Considerable experience has been gained with use of these instruments in esophagogastric anastomosis with distal esophageal resection through a left thoracotomy, with middle-third esophageal resection using the Ivor-Lewis approach, and with substernal gastric bypass and cervical esophagogastric anastomosis. 3, 10-12, 18, 25-27. 33, 37, 38 Despite the technical ease with which these anastomoses can be performed with circular stapling instruments, the complications of leakage and stricture have not been eliminated. The incidence of anastomotic leakage has been documented as 0 to 5% in various studies. 33, 38 However, routine contrast studies of the esophagus were not performed in many of these reports, and, therefore, these reports may underestimate the true incidence of leakage. Clinical evidence of formation of a stricture has been reported2, 10-12, 18,25-27,33,37,38 in 10% to 15.4% of patients. These complications
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can be minimized by adhering to the general principles of preserving adequate blood supply to the stomach and esophagus, avoiding tension on the anastomosis, and providing adequate decompression and adequate nutritional support to the patient. In addition, precise mucosa-to-mucosa apposition is important to reduce the incidence of leakage and benign anastomotic stricture in these patients. Furthermore, specific pitfalls inher~ ent in anastomotic construction with the stapling device should be avoided to reduce the incidence of leakage and stricture. One of the most common causes of an inadequate mucosa-to-mucosa approximation is tearing the esophageal mucosa with an oversized stapling cartridge. The stapling cartridge should easily pass into the proximal esophagus without tension on the mucosa. With a noncompliant proximal esophagus, the stapling head should be of a smaller size. When a tear of the mucosa occurs during introduction of the stapling cartridge, it is wise to resect a larger cuff of proximal esophagus beyond the point of injury to the muscularis, because the mucosal tear often extends more proximally than the muscular tear. Use of a smaller stapling cartridge prevents this complication. Another cause of leakage at the stapled esophagogastric anastomosis is an inadequate proximal esophageal pursestring suture. This suture must adequately cinch the esophageal mucosa and muscularis around the central shaft of the stapling device. To avoid gaps in the purse string suture line, a continuous 0 or 2-0 polypropylene (Prolene) suture is placed meticulously through both mucosa and muscular layers of the esophagus 2 to 3 mm from the cut edge, and enough bites, usually six to eight circumferentially, are taken to avoid gaps and puckering. Molina and colleagues25 described a technique for placement of the proximal pursestring suture that prevented retraction of the esophageal mucosa. They opened the anterior wall of the esophagus, started the pursestring suture around the anterior wall, detached the posterior wall of the esophagus, and continued the purse string suture circumferentially as they cut. To avoid retraction of the mucosa on the gastric side of the anastomosis, the smallest hole that will permit passage of the central shaft is made. Too large a hole will permit retraction of the gastric mucosa. When the stapling cartridge has been fired, gentle traction is applied on the instrument while supporting the anastomosis and withdrawing the instrument. The resulting rings of tissue are always examined to confirm the presence of two intact "doughnuts" of tissue from the gastric and esophageal ends. A defect in the continuity of these circular rings of tissue implies a lack of integrity of the anastomosis. The area in question should be reinforced with interrupted sutures, and consideration should be given to wrapping the area with omentum or a partial wrap with the stomach. Some authors 12, 38 advocate routine wrapping of these anastomoses, but most surgeons find this procedure unnecessary. The site of gastrotomy through which the stapling instrument was introduced should also be closed carefully because some reports 26, 37 have identified this suture line as a source of leakage. We routinely oversew all stapled gastric suture lines when the stomach is brought up into the chest. In addition, spacing of the gastrotomy and anastomotic site at least 2 to 3
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cm from the staple line in the gastric remnant helps to reduce the possibility of vascular compromise and resulting leakage. Various techniques for testing the anastomosis, including insufflation with air or saline solution, have been advocated, 18. 37 but such maneuvers are not necessary. With stapled anastomoses, anastomotic narrowing with formation of a stricture is a more common complication than leakage. In a large series reported by Muehrcke and coworkers,27 the incidence of benign stricture after esophagogastrectomy and end-to-end anastomosis with the circular stapling instrument was 12.5%. An inverse relationship appeared to exist between the incidence of benign stricture and the size of the stapling head, although these differences did not reach statistical significance. The incidence of stricture with the 31-mm stapling cartridge was 5.4%, 13.5% with the 28-mm stapling cartridge, and 17% with the 25-mm stapling cartridge. These figures suggest, and it usually follows, that a smaller anastomosis is more prone to the development of a stricture than a larger anastomosis, but the sample size was too small to prove this theory. The inclination to use the largest stapling head to avoid the complication of stricture should be offset by the more serious problem of mucosal tearing caused by an oversized stapling head and the potential lethal complication of leakage. For the most part, a benign esophageal anastomotic stricture that occurs after either a stapled or a hand-sewn anastomosis is easily managed with dilation and does not require further surgical intervention. 1. 18. 27 In summary, adherence to these technical points can minimize the potential complications associated with stapled esophagogastric anastomoses. End-to-End Anastomosis Since the introduction of the EEA stapler for rectal reconstruction, the technique has been modified so that the lower rectal segment is closed with a linear stapler (TA), and the anastomosis is performed using the EEA stapler across the linear staple line (combined or double-staple technique). 20 This double-staple technique obviates the difficulty associated with application of a pursestring suture on the lower rectal segment deep in the pelvis. Although theoretical concerns exist about the potential complications associated with intersecting staple lines, no problem has materialized clinically.28 Nevertheless, although the double-staple technique has enjoyed widespread popularity, it is important to pay meticulous attention to detail to avoid intraoperative pitfalls that may have immediate and long-term implications. The technique of low anterior resection and reconstruction by use of the stapler has been aided by recent modifications in the TA-55 (Roticulator 55; United States Surgical Corp.) and circular stapling devices (Premium CEEA; United States Surgical Corp.). In this procedure, a roticulating TA55 stapler is placed at the distal margin of resection. This instrument is particularly suited to placement low in the pelvis; the angle of the head can be altered to facilitate placement and to avoid the symphysis pubis. The instrument is fired after the surgeon has ascertained that no extraneous tissue is incorporated in the stapler. The specimen is transected proximal to the staple line. The perineal operator distends the rectal segment with
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povidone-iodine (Betadine) solution or saline solution. Any leakage from the staple line is easier to repair at this point than after the anastomosis has been completed. The colon is transected proximally. A pursestring suture is placed around the proximal end, and sizers are used to determine the size of the circular stapling instrument to be used. The appropriate Premium CEEA stapler with its centerpost and anvil removed is placed in the proximal bowel and secured with a whip stitch suture. Placement of the pursestring suture before use of the sizers prevents serosal splitting of the bowel. The trocar is withdrawn into the staple cartridge, and the instrument is introduced transanally to the top of the rectal pouch. Improper introduction of the stapler may in rare instances result in perforation of the posterior rectal wall. The trocar and centerpost are advanced, and the trocar is brought through the bowel immediately adjacent to the staple line. It is important not to leave a rim of tissue between the staple line and the trocar that could become ischemic. The anvil is guided down to the trocar and secured, and the instrument is fired. The instrument is disengaged and slowly withdrawn with a gentle rotational movement. Although the instrument is usually withdrawn easily, many problems can develop. Difficulty Extracting the Stapler. Difficulty in extracting the EEA stapler through the rectum, one of the most common intraoperative problems encountered, may result, in part, because the internal diameter of the anastomosis is smaller than that of the EEA stapler. In addition, the cutting blade of the EEA stapler may not have completely incised the rings of tissue. Vigorous attempts at withdrawal of the EEA stapler may result in disruption of the anastomosis or tearing of the bowel wall. This problem is avoided by gently rocking the instrument and by making larger circles while the abdominal operator supports the rectum distal to the anastomosis. When this procedure is unsuccessful, Lembert sutures may be placed distal to the anastomosis to help hold up the anterior lip of the anastomosis and to facilitate extraction of the instrument. As a last resort, a proximal colotomy can be made and the anvil removed through this area. Thorough inspection of the anastomosis is mandatory, particularly when extraction of the stapler was difficult. Incomplete Rings of Tissue. After the stapler is withdrawn, the rings of tissue are examined to ensure that they are intact and incorporate all layers of the bowel wall. The orientation of the rings of tissue is maintained on the centerpost of the EEA stapler because they assist the surgeon in the detection of the precise site of deficiency. Incomplete rings of tissue may result from failure to incorporate all layers of the bowel into the pursestring suture and slipped knots after the pursestring suture is secured. The integrity of the anastomosis can be ensured by direct inspection, by irrigation of the rectum with saline or povidone-iodine solution, or by air insufflation of the rectum. Leakage at the suture line, when encountered, is managed by suture closure. Intraoperative testing of the anastomosis has been shown to decrease Significantly the number of leakages seen clinically and radiologically. 2
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Anastomotic Leakage. Anastomotic leakage is the most serious perioperative complication. To prevent this complication, it is prudent to test the anastomosis intraoperatively by instillation of povidone-iodine or saline solution or air to assess for leakage. The incidence of anastomotic leakage varies. When the results of 10 series of 1483 patients were pooled, the clinical rate of leakage was 4.4%.16 The incidence of leakage is increased in low rectal anastomoses and may be increased in patients who have inadequate bowel preparation, poor blood supply to both ends of the bowel, and tension on the anastomosis. However, the most important factor in the prevention of anastomotic leakage appears to be surgical technique. 13 Rectovaginal or Rectovesical Fistula. The formation of a rectovaginal or rectovesical fistula is rare after stapled anastomosis. A rectovaginal fistula may occur after inadvertent incorporation of a portion of the vagina into the end-to-end anastomosis. Such an occurrence is more likely in women who have undergone previous hysterectomy. In these patients, the rectovaginal septum may be scarred and adherent and difficult to separate. A rectovaginal fistula may also result from anastomotic leakage or abscess that drains through the point of least resistance. Most patients in whom a rectovaginal fistula develops require proximal fecal diversion. Hemorrhage. Postoperative hemorrhage is an uncommon complication with use of the EEA stapler; it is usually from the staple line and is selflimited. In the patient with ongoing bleeding, transanal endoscopic visualization of the anastomosis can be performed and the bleeding point coagulated or suture ligated. Anastomotic Stricture. Although a stricture may form at the site of any anastomosis, its formation appears to be more common with use of the EEA stapler. The cause of an anastomotic stricture is multifactorial; stapled anastomoses heal by secondary intention because the mucosa of the bowel is not apposed but is separated by the muscular and serosal layers. 30 Healing of a stapled anastomosis results in a perfectly circular scar. The formation of an anastomotic stricture may be related to tension and resultant ischemia or to anastomotic leakage that subsequently causes fibrosis and formation of granulation tissue. The incidence of stricture varies and is determined by the surgeon's definition of stricture and by the inclusion of asymptomatic strictures. Some evidence of stricture is found in most anastomoses initially; commonly, a standard-size rigid sigmoidoscope cannot be passed beyond an anastomosis in the first 2 to 3 months after operation. With repeated passage of stool through the anastomosis, gradual dilation ensues. The use of bulk agents can also aid in dilation of the stricture. Subsequently, in a small number of patients, a symptomatic stricture persists. Stricture occurs more frequently after use of the 25-mm cartridge compared with the 28mm or 31-mm cartridge. Use of the 25-mm cartridge should be avoided. A hand-sewn anastomosis or alternative procedure should be considered when a larger cartridge cannot be used. Stricture also occurs more commonly in patients who have had proximal fecal diversion. One series 15 found that transverse colostomy was associated with a 36% incidence of stenosis compared with an 8% incidence of stenosis overall. A symptomatic stricture that persists beyond 3 months should be
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Figure 1. A stricture occurring after a double-stapled end-to-end anastomosis is shown. Through a rigid sigmoidoscope, fragments of tissue in three or four areas of the anastomosis are excised by standard biopsy forceps, and the stricture is dilated. (Reprinted with permission of the Lahey Clinic, Burlington, MA.)
B. Correct Figure 2. A functional end-to-end anastomosis is shown. It is preferable to stagger the staple lines (X, Y). (Reprinted with permission of the Lahey Clinic, Burlington, MA.)
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treated, as should asymptomatic strictures that do not permit passage of a flexible sigmoidoscope or colonoscope, thus precluding examination of the more proximal bowel. Such an occurrence is uncommon. In a collected series 16 of almost 1500 patients, the incidence of symptomatic stricture was only 1. 7%. Patients with such strictures can be treated by dilation with a bougie or a sigmoidoscope after excision of scar tissue of the anastomosis in three or four areas with standard biopsy forceps (Fig. 1). The excised fragments of tissue should be submitted for pathologic examination to exclude recurrent carcinoma. Functional End-to-End Anastomosis The functional end-to-end anastomosis, which employs the CIA and TA staplers, can be created for ileocolostomy, colocolostomy, or colorectostomy. To perform such an anastomosis, the bowel is transected proximally and distally with a CIA stapler. The remaining ends of bowel are brought together in parallel fashion, and an enterotomy is made on either end along the antimesenteric surface. The CIA forks are placed, one down the proximal end and the other down the distal end, and the instrument is fired. The staple line is inspected, and bleeding is controlled by either electrocautery or suture ligation. The anastomosis is completed by a TA-55 stapler. It is helpful to stagger the staple lines slightly (Fig. 2). Before the TA-55 stapler is fired, Allis clamps are placed on the bowel with particular attention paid to the corners to ensure that they are included.
SUMMARY The development of stapling instruments has been an enormous advancement in surgery of the gastrointestinal tract. No instrument, however, can replace sound surgical judgment and technique.
REFERENCES 1. Androsov PI: Experience in the application of the instrumental mechanical suture in surgery of the stomach and rectum. Acta Chir Scand 136:57-63, 1970 2. Beard JD, Nicholson ML, Sayers RD, et al: Intraoperative air testing of colorectal anastomoses: A prospective, randomized trial. Br J Surg 77:1095-1097, 1990 3. Behl PR, Holden MP, Brown AH: Three years' experience with esophageal stapling device. Ann Surg 198:134-136, 1983 4. Brenner M, Johnson DE: Ileal conduit calculi from stapler anastomosis: A long-term complication? Urology 26:537-540, 1985 5. Cajozzo M, Compagno G, DiTora P, et al: Advantages and disadvantages of mechanical versus manual anastomosis in colorectal surgery. Acta Chir Scand 156:167-169, 1990 6. Chassin JL, Rifkind KM, Sussman B, et al: The stapled gastrointestinal tract anastomosis: Incidence of postoperative complications compared with the sutured anastomosis. Ann Surg 188:689-696, 1978
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7. Chassin JL, Rifkind KM, Turner JW: Errors and pitfalls in stapling gastrointestinal tract anastomoses. Surg Clin North Am 64:441-459, 1984 8. Didolkar MS, Reed WP, Elias EG, et al: A prospective randomized study of sutured versus stapled bowel anastomoses in patients with cancer. Cancer 57:456-460, 1986 9. Di Matteo G, Cancrini A Jr, Palazzini G, et al: Stapled suture in digestive tract surgery. Int Surg 73:23-28, 1988 10. Donnelly RJ, Sastry MR, Wright CD: Oesophagogastrectomy using the end to end anastomotic stapler: Results of the first 100 patients. Thorax 40:958-959, 1985 11. Dorsey JS, Esses S, Goldberg M, et al: Esophagogastrectomy using the auto suture EEA surgical stapling instrument. Ann Thorac Surg 30:308-312, 1980 12. Fekete F, Breil P, Ronsse H, et al: EEA stapler and omental graft in esophagogastrectomy: Experience with 30 intrathoracic anastomoses for cancer. Ann Surg 193:825-830, 1981 13. Fielding LP, Stewart-Brown S, Blesovsky L, et al: Anastomotic integrity after operations for large-bowel cancer: A multicentre study. Br Med J 281:411-414, 1980 14. Fischer MG: Bleeding from stapler anastomosis. Am J Surg 131:745-747, 1976 15. Graffner H, Fredlund P, Olsson SA, et al: Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument: A randomized study. Dis Colon Rectum 26:87-90, 1983 16. Griffen FD, Knight CD, Whitaker JM, et al: The double stapling technique for low anterior resection: Results, modifications, and observations. Ann Surg 211:745-752, 1990 17. Hedberg SE, Helmy AH: Experience with gastrointestinal stapling at the Massachusetts General Hospital. Surg Clin North Am 64:511-528, 1984 18. Hopkins RA, Alexander JC, Postlethwait RW: Stapled esophagogastric anastomosis. Am J Surg 147:283-287, 1984 19. Hiilt! H: Cited in Surgical Stapling Techniques. Somerville, NJ, Ethicon, 1986 20. Knight CD, Griffen FD: An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 88:710-714, 1980 21. Latimer RG, Doane W A, McKittrick JE, et al: Automatic staple suturing for gastrointestinal surgery. Am J Surg 130:766-771, 1975 22. Lowdon IMR, Gear MWL, Kilby JO: Stapling instruments in upper gastrointestinal surgery: A retrospective study of 362 cases. Br J Surg 69:333-335, 1982 23. Mathisen DJ, Grillo HC, Wilkins EW Jr, et al: Transthoracic esophagectomy: A safe approach to carcinoma of the esophagus. Ann Thorac Surg 45:137-143, 1988 24. McManus KG, Ritchie AJ, McGuigan J, et al: Sutures, staplers, leaks and strictures: A review of anastomoses in oesophageal resection at Royal Victoria Hospital, Belfast 19771986. Eur J Cardio-thorac Surg 4:97-100, 1990 25. Molina JE, Lawton BR, Avance D: Use of circumferential stapler in reconstructions following resection for carcinoma of the cardia. Ann Thorac Surg 31:325-328, 1981 26. Muehrcke DD, Donnelly RJ: Complications after esophagogastrectomy using stapling instruments. Ann Thorac Surg 48:257-262, 1989 27. Muehrcke DD, Kaplan DK, Donnelly RJ: Anastomotic narrowing after esophagogastrectomy with the EEA stapling device. J Thorac Cardiovasc Surg 97:434-438, 1989 28. Nance FC: New techniques of gastrointestinal anastomoses with the EEA stapler. Ann Surg 189:587-600, 1979 29. Oakley AMM, Ive FA, Carr MM: Skin clips are contraindicated when there is nickel allergy. J R Soc Med 80:290-291, 1987 30. Penninckx FM, Kerremans RP, Geboes KJ: The healing of single- and double-row stapled circular anastomoses. Dis Colon Rectum 27:714-719, 1984 31. Reiling RB, Reiling W A Jr, Bernie W A, et al: Prospective controlled study of gastrointestinal stapled anastomoses. Am J Surg 139:147-152, 1980 32. Seufert RM, Schmidt-Matthiesen A, Beyer A: Total gastrectomy and oesophagojejunostomy: A prospective randomized trial of hand-sutured versus mechanically stapled anastomoses. Br J Surg 77:50-52, 1990 33. Shahinian TK, Bowen JR, Soderberg CH Jr, et al: Experience with the EEA stapling device. Am J Surg 139:549-553, 1980 34. Surgical Stapling Techniques. Somerville, NJ, Ethicon, 1986
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35. Tuchmann A, Dinstl K, Strasser K, et al: Stapling devices in gastrointestinal surgery. Int Surg 70:23-27, 1985 36. Werman BS, Rietschel RL: Chronic urticaria from tantalum staples. Arch Dermatol 117:438-439, 1981 37. West PN, Marbarger JP, Martz MN, et al: Esophagogastrectomy with the EEA stapler. Ann Surg 193:76-81, 1981 38. Wong J, Cheung H, Lui R, et al: Esophagogastric anastomosis performed with a stapler: The occurrence of leakage and stricture. Surgery 101:408-415, 1987
Address reprint requests to Patricia L. Roberts, MD Department of Colon and Rectal Surgery Lahey Clinic Medical Center 41 Mall Road Burlington, MA 01805