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Study Objective: To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications. Design: Retrospective study on data prospectively recorded in 2 databases. Setting: Two tertiary referral centers. Patients: A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. Interventions: Rectal disk excision using the EEA stapler. Measurement and Main Results: Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p = .027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months. Conclusion: Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.

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.

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.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.The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35.75 ± 17.51 vs 28.05 ± 10.23 cm(2), 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, P0.0001). Intraoperative haemostasis was better in the EEA group compared with the PPH01 and PPH03 groups. Postoperative bleeding occurred only in two PPH patients.Data suggest that the EEA stapler has better haemostatic properties than the PPH stapler and allows resection of a larger area of mucosal prolapse with potential benefits over the recurrence rate of haemorrhoid prolapse.

Our experiences concerning the end colostomy using the stapling method are reported. The anvil which has been inserted to the proximal end of the colon and purse string suture with the skin is engaged the anvil shaft, and then, is fired. This operative procedure is simple, safe and convenient, and we can expect a uniform and satisfactory outcome. We applied this technique on 6 cases and have had no postoperative complications., 我々が三年来施行している自動吻合器 (PREMIUM CEEA, 29 mm)を用いた人工肛門造設術について, 手術手技, 臨床成績の観点から述べた. 造設部位に直径 1. 5cm の円形の皮膚, 皮下脂肪組織の欠損部を造り, 近位結腸端を型どおりの方法で腹壁を通しこの欠損部に誘導する. この結腸端に巾着縫合をかけ, アンビルを挿入・固定する. この結腸と腹壁筋膜を4針縫合・固定後, 皮膚欠損部の周囲に巾着縫合の糸をかける. アンビルとアンビルシャフトを結合させた後, 皮膚の巾着縫合を締め, 吻合器のハンドルを締めてファイアーする. 臨床的に6例に応用し, 合併症は認めなかった. 本術式のポイントは吻合器のハンドルをきつすぎず, 緩すぎず締めることで, きつすぎると結腸・皮膚間が離開し, 人工肛門の狭窄を, 緩すぎると出血, 感染を来すであろう. 皮膚に残るステイプルは肉芽組織で覆われるものから脱落するものまで様々であるが, 放置しておいても何ら問題はない.

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.