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Marginal ulceration (MU) and bleeding are possible complications following laparoscopic Roux-en-Y gastric bypass (RYGB). Our institution utilizes three techniques for performing the gastrojejunal anastomosis (GJA), providing a means to compare postoperative MU and bleeding as it relates to GJA technique. We sought to analyze the incidence of MU and bleeding between the 25-mm end-to-end anastomosis (EEA) stapler, linear stapler (LS), and robotic hand-sewn (RHS) GJA techniques. Electronic health records for all patients who had an upper endoscopy (EGD) after RYGB were queried (2010–2014). Charts were retrospectively reviewed for type of GJA, complications, endoscopic interventions, and smoking and NSAID use. Out of 1112 RYGBs, the GJA was created using an EEA, LS, or RHS approach in 58.6%, 33.6%, and 7.7% of patients, respectively. 17.4% had an EGD (19.9% EEA, 13.9% LS, and 14.0% RHS). Incidence of MU was 7.3% (9.3% EEA, 4.8% LS, and 5.8% RHS). Rates of EGD and MU were significantly higher after EEA vs. LS GJA (p

Several well-described methods exist for creating the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass. The most common methods include a circular stapled anastomosis using the EEA stapler and a linear-stapled anastomosis using a gastrointestinal anastomosis (GIA) stapler followed by a hand-sewn or stapled closure of the common gastroenterotomy. A third approach utilizes a fully hand-sewn technique. These varied technical approaches provide different aperture sizes which may influence post-operative weight loss and weight recidivism as well as post-operative complications, especially gastrojejunal anastomotic stricture rates.

While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB. In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher’s exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student’s t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities. Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs. Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

Aim The study aimed in a multicentric randomised controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with stage III haemorrhoids undergoing stapled haemorrhoidopexy . Method 135 patients were randomised to treatment with PPH01/03 or an EEA stapler. They were reviewed after a minimum follow-up of four years to determine the rate of recurrent mucosal prolapse, and general condition (Wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria. Results 87 (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3±5.4 months and 49.0±5.3 months respectively). In the EEA-group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH-group (p=0.409). Persistence of anal bleeding was significantly higher in the PPH-group (p=0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA-group (1.73±1.65 vs 3.17±1.94, p

Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections. A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25–29 mm or 30–33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications. Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25–29 mm group and 288 (60.9%) in the 30–33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30–33 mm than with the 25–29 mm stapler (57.6% vs 28.6%, p

Perforation of the rectal stump during end-to-end anastomosis should be prevented. In case of perforation, repair approach depends on the amount of disruption and the residual length of the rectum. Diverting stoma should be considered in all cases.

Routine endoscopic inspection of the anastomosis and interventions when indicated can prevent postoperative hemorrhage. Endoscopic interventions are effective in treating postoperative anastomotic bleeding.

Circular staplers can be difficult to remove after creating an anastomosis. This chapter reviews some of the techniques to use with an EEA stapler gets caught in the tissues.

Aim Stapled haemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan–Morgan hemorrhoidectomy. The aim was to investigate a new stapler device designed to overcome these side effects. Method In all, 135 patients (71 men, mean age 42 years) with degree III haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH® staplers (Ethicon EndoSurgery) (63 patients) or with an EEA® stapler (Covidien) (72 patients) in four referral colorectal centres. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in square centimetres) and any postoperative bleeding within 30 days were recorded. Results The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35.75± 17.51 vs 28.05 ± 10.23 cm2, P = 0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median value 1, vs 3, interquartile range 0–2, vs 2–5, P

Background Minimally invasive esophagectomy (MIE) has been performed using a variety of techniques evolving during the past decade. We present our initial experience and outcomes of patients undergoing transthoracic MIE using a circular end-to-side anastomosis created with the transorally directed EEA circular stapler OrVil (Covidien, New Haven, CT). Complications, including anastomotic leak and stricture occurrence, are reviewed. Methods A retrospective review evaluated consecutive patients undergoing MIE for esophageal cancer or related disease with intrathoracic end-to-side anastomoses using the transorally directed EEA circular stapler from December 2007 to May 2010. Medical records were reviewed for demographics, staging, neoadjuvant chemoradiotherapy, comorbidities, adjuvant therapy, complications, and survival. Results During this period, 51 consecutive patients (84% male; mean age, 65 years) underwent MIE. Neoadjuvant chemoradiotherapy was performed in 32 patients, and 4 had intraoperative radiotherapy. Mean operative time was 338 minutes (range, 211 to 565 minutes), including the 4 patients with intraoperative radiotherapy. Operative time improved with experience (excluding intraoperative radiotherapy) from a mean of 378 minutes (patients 1 to 14) to 300 minutes (patients 37 to 51). Median hospital stay was 11 days (range, 6 to 48 days). Anastomotic leaks occurred in 5 patients (9.8%). Postoperative deaths included 1 in-hospital (2.0%) and 2 (3.9%) after discharge. Stricture was diagnosed and treated in 7 patients (13.7%). Follow-up was a median of 12 months (range, 1 to 31 months). Conclusions Transthoracic MIE using an end-to-side anastomosis with the transorally directed EEA circular stapler resulted in acceptable stricture and leak rates with good outcomes comparable to published outcomes for open surgical resections.

A new technique for the restoration of the continuity of the colon with preservation of an existing colostomy is described here. A 75-year-old male with a three-year history of abdominal-perineal resection and a well functioning end colostomy was admitted to our department for a second primary cancer of the descending colon. At operation the colon was divided close to the abdominal wall; the colostomy was left in situ while the descending colon and mesocolon were radically resected. The viability of the colostomy was being continuously inspected. An EEA stapler was then inserted through the colostomy and an anastomosis was created. Shortening the length of the operation and avoiding the possible complications that follow the creation of a new stoma are the major benefits of the technique. Still, the viability of the colostomy after its separation of the rest of the colon and mesocolon has to be ensured before proceeding.

腸管吻合においてステープル吻合器(以下EEA)と圧挫式無縫合吻合器(以下AKA-2)による縫合を実験的に作成し縫合不全の発生頻度,吻合部耐圧度,肉眼的観察,組織修複反応について検討し,創傷治癒の過程から安全性および信頼性を検討した.術前縫合不全の発生頻度は,腸管内非洗浄群ではAKA-2(54.5%),とEEA(11.1%)に比べて高かった.吻合部耐圧度は,術後2日目でAKA-2は100mmHg以下とEEAに比べて極端に低かった.吻合部の内翻腸管は,EEAでは血行が十分保たれていた.内翻腸管をリングで圧挫・把持するAKA-2では術後早期に内翻腸管は退縮し,血流低下による血行障害で,両腸管を翻転した癒合部が完成する前にリングが脱落するので,耐圧度が低下し,何らかの原因が加って内圧が上昇すると縫合不全の危険性が高まると考えられた.

One hundred seventy-seven patients underwent total gastrectomy for gastric cancer. Rates of complication and death after stapled anastomoses were compared retrospectively with those after sutured anastomoses. In 155 patients esophagojejunostomy was performed with the EEA stapler and in 22 patients hand sutures were employed. No major differences could be noted among the background factors of the two groups. Roux-en-Y anastomosis was the most frequent mode of reconstruction performed in the stapled group. The rate of leakage was 3.8% in the former and 9.0% in the latter with no significant difference. Three patients (1.9%) died within 30 days of stapled anastomosis and in one of them death was caused by anastomotic leakage. There was one case (4.5%) of post-operative death in the sutured group. It seemed that the stapler was able to secure and facilitate esophagojejunostomy after total gastrectomy.

A 31-year-old woman diagnosed having an adenocarcinoma of the rectum have had a low anterior resection using the EEA stapler. The size of cartridge was 31-mm, and the distal pursestring suture was applied manually as a continuous over-and-over suture, the proximal pursestring suture being made by the pursestring instrument. After 9-month from the last operation, a hard mass was palpated by the trans-anal digital examination. A local recurrence was suspected. Barium enema and colonoscopic findings were of a submucosal tumor. CT revealed the cystic mass at the part of anastomosis. So, a transanal tumor extirpation was performed. The pathological findings of the tumor were of atrophic residual mucosa and inflammatory change of the surrounding muscle. The cause of this cyst formation wound be excessive tissues enclosed in the EEA cartridge at the anastomosis. CT was useful for the differentiation from the local recurrence of the rectal cancer.

Objective The technique of transanally introducing a circular stapled device to accomplish colorectal anastomoses has been widely used. However, the widespread popularity of this technique may have created the potential of anal sphincter injury during transanal insertion of the anastomosing stapler. Thus, to avoid the risk of anal sphincter injury during anal manipulation, we have been performing an abdominal approach, namely abdominal stapled side-to-end anastomosis (ASSEA) using a Purstring and premium curved EEA stapler in low and high anterior resection. This study will present our experience and results of consecutive resections. Methods ASSEA following a resection of the rectum and sigmoid colon for carcinomas was consecutively performed between October 1998 and May 2002. Age, sex, pre-operative anal function, the TNM classification by the UICC rules, operative methods, postoperative morbidity, mortality, anal function and bowel frequency were evaluated. Results Sixty-nine consecutive patients underwent a resection of the rectum and sigmoid colon with ASSEA. There were three (4.3%) clinical anastomotic leakages in the cases studied. Anastomoses that were located above the peritoneal reflection leaked in one (2.5%) of 40 cases, while anastomoses below the peritoneal reflection leaked in two (6.9%) of 29 cases. A diverting stoma was performed in five (17%) of the 29 cases with low anastomosis. Postoperative anal function was stable without soiling or faecal leakage and bowel frequency two months after surgery was less than four times in all 61 patients. There was no postoperative mortality related to the anastomosis. Conclusions Abdominal stapled side-to-end anastomosis(Baker type)was found to be a safe and relatively easy method in both low and high anterior resection in association with a good quality of life.

Spasm of the proximal sigmoid colon has been a major hindrance in the use of the EEA stapler in low anterior resections. Intravenous glucagon, by causing rapid relaxation and hypotonicity of the sigmoid colon, appears to help correct this problem and allows for a safer and more atraumatic anastomosis.

In the initial clinical experience using the EEA stapler in twenty patients there were no instances of anastomotic leakage in five patients undergoing sigmoid colectomy and partial upper rectal excision or high anterior resection of the rectum. There were five Instances of confirmed anastomotic leakage (radiological or autopsy) of fifteen patients undergoing low anterior resection of the rectum. Benign anastomotic stenosis developed In three patients. The technique of anastomosis after low anterior resection remains a challenge and there is no justification lor less stringent training in hand sewn anastomoses because of the introduction of the EEA stapler.

A randomized, prospective study should be done to evaluate any new procedure or instrument. Our experience with the end-to-end anastomosis (EEA) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional hand-sewn technique. This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis. There appears to be little difference in the security of a hand-sewn anastomosis compared with that of stapled anastomosis. Postoperative complications appear similar. With the stapler, however, there is an increased risk of intraoperative complications that are not apparent with the traditional hand-sewn technique. These include rectal tears and anastomotic defects. It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis.

A Russian stapler and an EEA stapler were used for end-to-end anastomosis of the canine descending colon. The vascular structures of the anastomotic sites were investigated for postoperative changes at two, three, four, five, and six weeks after anastomosis by using the resin-casting method, with a scanning electron microscope. The two techniques of anastomotic stapling led to the following differences: at two weeks or more following anastomosis, it was found that, compared with the EEA stapler, the site stapled with the Russian device showed a slightly more markedly irregular microvascular pattern of the capillary network in the mucosal membranes along the anastomotic suture line and what were believed to be microulcerations as well. Samples of the Russian stapler at two and three weeks postoperatively showed that the fault zones had developed in the vascular casts of the mucosal capillary system between the area of irregular vasculature and the normal mucosa. It was clearly established, however, that the microvascular channels in the mucosal membrane of the anastomotic site across the orad and anad segments of the colon had already formed after two weeks with both of the stapling techniques. New microvessels grew within a range of about 10 mu in diameter from the cut-off surface of the mucosa and united. No necrotic destruction of tissue or deficiency findings had manifested themselves in the inverted cuff zone of the anastomotic site, and the staple had been enveloped by the blood vessels of the submucosal layer and embedded in the intestinal wall during the period of two to six weeks. New microvessels, 10 to 15 mu in diameter, were found to have already formed in the two-week samples, passing vertically across the lumen of the closed eye of the staple, and no differences in vascular structure were detected, depending on the different shapes of staples used. Five to six weeks after the anastomotic surgery, the mucosal membranes in the anastomotic site showed a normal vascular structure with only minute residual indentations.

The end-to-end anastomosis by stapling for left colonic and rectal resections is proving to be a relatively safe and fast procedure. Results of a survey of the American Society of Colon and Rectal Surgeons reveals 15.1 per cent intraoperative complications, 3.7 per cent early postoperative complications, 0.5 per cent deaths, and 13.8 per cent late complications. The majority of late complications, stenosis and incontinence, were either subclinical or transient for most patients. Technique and prevention of complications are stressed.

From March 1979 to January 1983, 250 consecutive patients underwent a left colectomy (LC; n = 119) or an anterior resection (ARR; n = 131). The colorectal anastomoses were constructed with the EEA stapler. After ARR, 56 sutures were low (at 7 cm or less from the dentate line) and 75 high. 8% of the sutures would have been probably impossible without the gun. The mortality rate was 2.8%. At autopsy, only 1 death could be related to an intestinal problem. Anastomotic leaks were observed in 6% of the cases, all after ARR (11.4%). The leaks were twice as frequent after low sutures (16%) than after high sutures (8%). Late severe consequences developed in only 2 patients. The reliability of the results was confirmed at long term. The majority of the patients were symptom-free as early as 6 months after the operation, and X-ray controls exhibited a large normal suture in about 70% of the patients. The EEA appears to be a satisfactory means of performing safe low colorectal sutures.

In a prospective clinical study 100 left-side colon and anterior rectum resections were performed without a protective colostomy under standardized conditions: Whole gut lavage, oral and systemic antibiotic prophylaxis, parenteral highcaloric nutrition perioperatively, anastomosing technique end to end, single layer, with atraumatic sutures (3 X 0 Vicryl, Dexon) or EEA stapler. A clinically relevant insufficiency of the anastomosis was seen in 4%, wound-healing impairment in 7%, only one patient died. Due to careful preparation and operation technique the frequency of septic complications and mortality nowadays is very low. On the other side a protective colostomy is afflicted with psychical problems to the patient, higher costs because of the longer period of hospitalization and a not unimportant number of complications of colostomy closure. Therefore we consider the routine usage of protective colostomy as not being necessary in elective colon and anterior rectum resections.

Transaction of the esophagus with use of the EEA stapler in uncontrollable hemorrhage from esophageal varices, combined with ligation of the splenic artery and the coronary vein, is presented. This technique was used in three patients with severe hemorrhaging from esophageal varices. Bleeding was controlled in all patients.

Over a three-year period, 1980-82, 79 per cent of our patients with rectal cancer were treated with the intention of cure, and sphincter-saving procedures were performed in 62 per cent of these cases. This report concerns 21 patients with mid-rectum cancer operated on with low anterior resection and extraperitoneal EEA-stapled anastomosis. Nine patients had Dukes' stage A tumors, seven had stage B, and five had stage C tumors. An 86-year-old woman died in the sixth postoperative week, and a 74-year-old man died after 20 months with a probable recurrence. Nineteen patients are currently alive 4 to 40 months post-operatively, with no overt signs of recurrence. We cannot confirm recent alarming reports on a significant incidence of early local recurrence. Routine Gastrografin enemas were performed and offered very little in terms of clinical guidance. Significant anastomotic leakage occurred in four patients, although without clinical symptoms or the need for fecal diversion. Despite initially intact anastomoses in 13 patients, pelvic sepsis with late dehiscence developed in three, all of whom required fecal diversion. The clinical leak rate was thus 3 of 21, 14 per cent, and the total incidence of leakage 7 of 21, 33 per cent. We performed routine colostomy on the first three patients but, in retrospect, believe this was unneccessary. Only one of the 19 survivors still has a colostomy, due to a benign anastomotic stricture. We consider anterior resection of mid-rectum carcinoma with EEA-stapled anastomosis a highly feasible procedure, the curative potential of which, however, can be established only by long-term follow-up studies.

For the patient with carcinoma of the esophagus in whom curative resection is not feasible, palliative procedures are often possible. Substernal gastric bypass is one of those palliative procedures. Although it does improve the quality of life, substernal gastric bypass is a major surgical procedure in a debilitated patient. Use of the EEA stapler to effect the gastroesophageal anastomosis, as reported here, simplifies and shortens the procedure.

The integrity of a stapled anastomosis of the small bowel to the gallbladder with malignant distal biliary obstruction was investigated. Seven dogs were studied during a 52 week period following completion of a cholecystoenterostomy (Roux-Y) with an EEA stapler for bypass of a ligated common bile duct. A widely patent and secure anastomotic line was documented. Three human patients with unresectable cancer of the head of the pancreas who underwent stapled cholecystojejunostomies received excellent palliation as well. Cholecystojejunostomy with the EEA stapler is a rapid and safe procedure for unresectable, malignant distal biliary obstruction.

We previously reported a new technique for handling the EEA stapler for anastomosis of the cervical esophagus and the retrosternally shifted gastric tube after subtotal esophagectomy for cancer of the esophagus. This report describes the results of the application of the technique in 15 patients.

The EEA stapler has been used at Wellington Hospital in 83 patients. The use of the instrument in 72 patients with colorectal disease is described. Fifty-one patients had malignant disease. Prior bowel preparation and perioperative antibiotics were used routinely. A 'low' anastomosis was performed in 26 patients. Complications relating to the integrity of the anastomosis occurred most frequently in low rectal cases and did not appear to be influenced by the presence or absence of a diverting colostomy. Tumour clearance was compromised (less than two centimetres) in 10 out of 23 patients with 'low' tumours. Two staple line recurrences occurred in this group.

The authors report their experience with forty patients undergoing resection of middle and lower thirds carcinomas of the esophagus or proximal stomach, with esophagogastric or esophagojejunal anastomosis using an end-to-end anastomosis (EEA) stapler. A fatal anastomotic leak occurred in the first two patients and seven other patients died in the early postoperative period from respiratory and cardiovascular complications. Four other patients developed fibrotic strictures between 6 and 24 months after their operation. The strictures were easily dilated and did not recur. The use of an EEA stapler is recommended because it reduces the operating time, the incidence of anastomotic leaks, and probably the blood loss. The majority of anastomoses can be accomplished exclusively through the left chest by using the stapler.

Nine local recurrences have been diagnosed in 38 patients with carcinoma of the rectum operated on with anterior resection using the EEA-stapling instrument. The characteristics of these recurrences have been compared with those of other authors, currently a total of 27 recurrences. The presence of a locally advanced growth with extramural spread, a distal location and a short margin of clearance seems to increase the risk of local recurrence, with often distressing symptoms. It is proposed that even if the EEA-stapler offers technical possibilities for anterior resection in these growths, this operation should be restricted to less advanced tumours.

We have described a new technique for side-to-side gastrojejunostomy as performed in Billroth II gastrectomy and for end-to-side ileocolostomy after right hemicolectomy utilizing the EEA stapler. By introducing the stapler through the area to be resected, we eliminated the need to close insertion enterostomies. This stapling technique also reduces the hazards and complications associated with multiple pursestring sutures normally required for end-to-end anastomosis with the EEA stapler, since, at most, one such suture is used. With minor modifications, the surgical technique can be applied to other operations in the alimentary tract, thus enhancing the utility of the EEA surgical stapler.

Transabdominal esophageal mucosal transection for control of bleeding esophageal varices has been used in our clinic since 1972. The most difficult part in this procedure is the reanastomosis of the transected mucosal tube. To facilitate this procedure, end-to-end anastomosis (EEA) stapling instrument has been in use since July, 1980. Thirteen patients have so far undergone this procedure and there have been no complications. The technique of anastomosis of the mucosal tube is described herein.

This report details an intraoperative complication with the anvil of the EEA stapler in the course of a Mason vertical banded gastroplasty for morbid obesity. It was unrecognized by the operating team, and resulted in prolongation of the procedure, excessive manipulation of the stomach, and the use of a second EEA stapling instrument.

THE EEA STAPLING INSTRUMENT has p roven its value in low rectal anastomosis procedures. It is reco m m e n d e d that one use the largest cartridge of the EEA device that will fit easily into the lumen of the bowel, x One technical problem that is frequently enc o u n t e r e d is the dissimilar diameters of the bowel ends and the difficulty in in t roducing the cartr idge into the smaller of the intestinal lumina. This is especially true when the device is passed upward th rough the anus. 2"3 The distal rectal segment easily accommodates the staple cartridge, but one may have great difficulty in in t roducing the anvil into the smaller proximal bowel without lacerating the bowel wall. A simple technique for enlarging the bowel lumen is described.

The overall local recurrence rate following resection of colorectal cancer with restoration of continuity with staples in Wellington was 24%. Nine of 11 patients with local recurrence following resection of rectal tumours had distant metastases at the time of diagnosis of their local recurrence. Using a predictive model to retrospectively estimate the probability of local recurrence it was found that nine of these 11 patients would have been expected to have had a lower local recurrence rate had they undergone abdominoperineal resection of the rectum initially. Since local recurrence is simply a local manifestation of systemic disease in 90% of patients, however, it is suggested that patients would prefer restoration of bowel continuity in preference to rectal excision and stoma formation, there being such little survival advantage for the latter procedure. The utility of the predictive model is therefore questioned.

The use of the End-to-End Anastomosis (EEA) circumferential stapler for reconstruction following resection of the esophagus and stomach for carcinoma of the cardia is reported here in 9 consecutive patients with fifteen anastomoses performed with this unit. The technical aspects of the EEA stapler are emphasized. Two frequent problems associated with this type of operation, namely, stenosis or leak at the suture line, are completely avoided by the use of this stapler unit. Its use is recommended.

The EEA stapler is a convenient, well-designed, and reliable instrument. It will anastomose the bowel with reliability and speed at least equivalent to hand-sewn techniques, and probably offers a technical advantage in performing very low rectal anastomoses. Unfortunately, intraoperative misadventures are greater with this device than with hand-sewn techniques, and its use would seem best restricted to those situations in which it has its greatest advantage. Postoperative complications are not increased by its use, but the long-term incidence of anastomotic stricture and possibly increased rate of local recurrence need to be clarified.

The EEA stapler now offers an alternative to hand-sewn techniques for primary and staged low colorectal anastomoses. The stapler may allow a safer and lower resection than was previously possible. A review of 52 primary and 8 staged EEA anastomoses is presented, with emphasis on the combined stapler technique.

Summary A technique for the extended use of GIA and EEA or ILS staplers in the easy construction of an ileal J-pouch and mucosal proctectomy has been described herein. The technique for construction of the J-pouch involves the almost exclusive multiple use of a GIA stapling device. The described mucosal proctectomy techniques use the EEA stapler for good traction and visualization for everted electrocautery suction mucosal dissection. With the use of these techniques, the integrity of the patient's tissue is preserved, suture lines are stronger, and the operating time is greatly reduced.