technique of gastric stapled resection: preliminary report
Autori: M. Franzini, F. Pirondi, A. Lucchini, P. P. Puviani,
A. Savioli, M. Tosi, G. L. Liera
Ospedale Comprensoriale di Guastalla, Reggio Emilia
Divisione di Chirurgia Generale (Primario: Dr. M. Franzini)
Since mechanical staplers have been introduced to perform gastro-jejunal
anastomosis and gastrectomy procedures, a number of techniques have been
proposed with the twofold purpose to facilitate the procedure and shorten
the operation time.
Moreover the stapled technique of gastrectomy has proved to be of easy
learning for junior surgeons and of handy application. Of great efficacy
is their application in emergency, in re-resection procedures and in
the treatment of dumping syndrome.
Stapled gastrectomy must be considered an elective method for this procedures,
as it makes possible homogeneous and safe resections and reconstructions
that are proper for this surgery which is burdened with heavy complications.
Advantages and results of the personal technique are reported herein.
The diffusion of stapling instruments in the common practice of digestive
surgery has favoured different technical options for reconstructive procedures,
regarding to the reliability and perfection of the suture and shortening
of the operative time.
In consideration of the best results both at long and medium terms,
our technique of choice consists nowadays in a gastric resection with
a Roux-en-Y reconstruction. This technique requires the use
of only mechanical staplers and should permit its extensive application
also in the hands of the less experienced surgeons.
Herein, we present the developed technique and the results of one year
long experience with this procedure.
MATERIAL AND METHODS
Between October 1988 and September 1989 at our Institution 49 patients,
35 males and 14 females, aged between 38 and 83, underwent an operation
of gastric resection.
Only cases of peptic ulcer, gastric tumor or dumping syndrome were selected.
39 patients suffered from antro-pyloric malignancies, 8 patients were
operated on for gastric ulcer and 2 for dumping syndrome in Billroth II
gastroenterostomized. In these cases a variably extended distal gastic
resection represented the operation of choice and the steps of gastric
scheletyzation or associated deletions is not different from the
Through an upper midline incision the gastric antrum, pylorus, and first
2 cm of the duodenum are devascularized in the usual manner. Gastric
scheletyzation is proximally extended according to location of the
The various steps of our technique are listed in Table I. Jejunal loop is
delivered into the supracolic region either through the transverse mesocolon
or anterior to the transverse colon.
Gastro-jejunal suction is generally prolonged till the 5th-6th
postoperative day, then food intake is gradually restored.
RESULTS AND CONCLUSIONS
Of the 49 patients who had the gastrectomy by this stapled method,
4 had an early postoperative hemorrhage from the gastro-jejunal
anastomosis that didn't require any blood replacement.
This experience induced us to control the gastro-jejunal anastomosis
after GIA retraction from the gastro-jejunal lumen.
In fact a mild hemorrhage was often observed after the GIA sutures and
some stitches were applied from inside the lumen.
The only significant complication consisted in a duodenal leak which
began 12 days after the operation when the drain had already been removed.
Such a complication required a drainage re-operation. The patient
was discharged after 32 days.
This patient was operated on for an antro-pyloric neoplasm, but at
a follow-up of 10 months no recurrence is demonstrated.
In all the cases the functional recuperation was regular and precocious.
In one case - a 45-year old woman operated on for gastric ulcer
and mild grade dysplasia - a postanastomotic ulcer appeared one
month after gastrectomy in spite of the gastroprotective therapy by
We had no case of mortality.Our preliminary results and the literature
reports (1,2,3,4) demonstrate that the use of staplers in the
performance of gastrectomies is at least as safe than the use of
The two main advantages of the stapled sutures are expediency and
Besides there is no doubt that the use of the staplers can easily be
learned and is safer in the hands of a less experienced surgeon than
hand-suture methods (4).
Yet it must be underlined that also stapled sutures can fail to secure
closure of tumorous or infected tissues just as hand suture methods do
The technique reported here differs from other stapled gastrectomies
in that the EEA staplers are avoided. According to our opinion EEA
staplers are more complex to use and may be responsible of various
complications, such as leaks, an incomplete "doughnut",
split bowel, inability to use the instruments because of insufficient
bowel diameter and difficulty to dislodge the head of the stapler from
the anastomosis (2).
Another complication that we observed in the esophago-gastric
anastomosis with the use of EEA stapler is the stenosis of the suture
line and this complication is also reported by other Authors (3).
Stenosis of an end-to-end stapled anastomosis was never observed
by us after total gastrectomies but in two cases of esophago-gastric
resection early from the operation and we believe that gastric secretion
or acid reflux can favour this complication.
On the contrary the GIA stapler allows a very wide gastro-jejunal
anastomosis also in presence of a small calibre bowel.
For the reasons given above we think that the GIA stapler is the
instrument of choice for gastro-jejunal anastomosis and we dissent
from those who (1,2,3) support the EEA stapler for this use.
Table I: Technique of stapled gastric resection
closure of duodenal stump with a TA55 stapler;
gastrectomy performed by applying a TA90 stapler;
mobilization and sectioning of the 3rd or 4th jejunal loop by
applying a GIA50 stapler;
side-to-side gastro-jejunal anastomosis on the posterior
wall of the stomach with a GIA50 stapler; gastro jejunal anastomosis is
performed 2 cm proximally to the stapled gastric stump; the enterotomy
is closed with a transverse TA30 staple line;
Roux-en-Y side-to-side jejunal anastomosis 50 cm
distal to the gastro-jejunal anastomosis with a GIA50 stapler;
the enterotomy is closed with a transverse TA30 staple line.
CHUNG R. S., SILLIN L. F.: Side-to-side
Anastomosis in Partial Gastrectomy And Hemicolectomy Using the EEA
Stapler. Am. J. Surg., 149:683-685, 1985.
NANCE F. C.: New Techniques of Gastrointestinal Anastomoses with the
EEA Stapler. Ann. Surg., 189: 587-600, 1979.
OREFICE S., CUSUMANO F., TURATTI G., SALVADORI B.: Tecnica di ricostruzione
chirurgica dopo gastrectomia subtotale con il solo impiego di suturatrici
meccaniche. Chirurgia, 2: 696-699, 1989.
WEIL P. H., SCHERZ H.: Comparison of Stapled and Hand-Sutured
Gastrectomies. Arch. Surg., 116: 14-16, 1981.