Our technique of gastric stapled resection: 
preliminary report and results

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)
SUMMARY

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.

INTRODUCTION

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 traditional technique.
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 lesion.
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 ranitidine.
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 hand-suture methods.
The two main advantages of the stapled sutures are expediency and time-saving.
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 (4).
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
  1. closure of duodenal stump with a TA55 stapler;
  2. gastrectomy performed by applying a TA90 stapler;
  3. mobilization and sectioning of the 3rd or 4th jejunal loop by applying a GIA50 stapler;
  4. 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;
  5. 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.
REFERENCES
  1. 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.
  2. NANCE F. C.: New Techniques of Gastrointestinal Anastomoses with the EEA Stapler. Ann. Surg., 189: 587-600, 1979.
  3. 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.
  4. WEIL P. H., SCHERZ H.: Comparison of Stapled and Hand-Sutured Gastrectomies. Arch. Surg., 116: 14-16, 1981.