Gastro-Esophageal Anastomosis Using the

Automatic Pursestringer and Circular Stapling Device

Walter A. Koltun, MD

ne of the more difficult components of a subtotal or

total gastrectomy is the esophageal anastomosis. This is
because of the frequently difficult exposure at the hiatus of
the diaphragm or posterior mediastinum, making a handsewn anastomosis problematic. The use of the circular stapler
and the automatic pursestringer facilitates the creation of this
anastomosis from the abdominal approach. This technique
not only eases the difficulty of anastomosis creation, but also
provides for improved control of the transected esophagus,
especially when additional tissue needs to be resected to increase a proximal resection margin.

Operative Technique
Once the major part of the gastrectomy has been performed, including the peri-esophageal dissection to the
proximal extent desired, the automatic pursestringer is
placed across the esophagus at the planned point of transection. The instrument is fired and left locked. The esophagus is
transected below the instrument (Fig 1). The handle of the
automatic pursestringer now provides excellent control of
the transected esophagus and inhibits its retraction up into
the posterior mediastinum. The specimen is passed off and if
necessary, frozen sections are done of the proximal resection
margin. If additional resection is necessary, the automatic
pursestringer allows uniform traction on the esophagus as
more proximal dissection is done. If the resection of additional esophagus is necessary, a right angle bowel clamp is
placed just above the pursestringer that is then removed.
Further dissection is performed and then a second purseDepartment of Surgery, Division of Colon and Rectal Surgery, Penn State
College of Medicine, Milton S. Hershey Medical Center, Hershey, PA.
Address reprint requests to Walter A. Koltun, MD, Professor of Surgery,
Division of Colon and Rectal Surgery, Penn State College of Medicine,
Milton S. Hershey Medical Center, 500 University Drive, MCH137, Hershey, PA 17033-0850. E-mail: wkoltun@hmc.psu.edu

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1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2008.10.002

stringer is placed higher up at the new resection margin and

once again fired. The additional esophageal tissue caudad to
this second pursestringer is then resected for added margin.
If the operator is satisfied with the level of proximal resection, a long Babcock clamp is then placed on the esophagus 2
to 4 cm above the pursestringer to provide control while the
pursestringer is removed, leaving the pursestring suture in
position on the cut end of the esophagus. The anvil from the
appropriately sized circular stapler is then placed within the
esophagus using Allis clamps to control and spread the cut
edges of the esophagus (Fig 2). If desired, the circular stapler
sizers can first be used to define or dilate the size of the
esophagus to allow the largest reasonable circular stapling
instrument to be used. After placement of the anvil, the
pursestring is tied down and the long Babcock clamp removed. The esophagus with its anvil will typically retract
several centimeters upward, but will be easily retrieved by
grasping the pin of the anvil when the anastomosis is to be
subsequently created.
The distal half of the anastomosis is then prepared by
ensuring adequate mobility of either the remaining stomach
or other intestinal structure. An enterotomy is created in the
side of the downstream viscus, several centimeters from the
planned anastomosis. This allows the entry of the hand-held
portion of the circular stapling instrument and the end of the
instrument is positioned to have the spike exit the viscus at
the planned, distal half of the anastomosis. The anvil containing esophagus is retrieved from the posterior mediastinum
and is engaged with the hand held portion of the instrument
(Fig 3). The circular stapler is closed and fired, creating the
anastomosis. If reinforcing sutures are desired, placing them
in four quadrants across the anastomosis can be done while
the EEA is still closed and in place but not tying them down
until the stapler is removed. The instrument is opened and
removed through the defect in the downstream viscera that is
then closed with either a TA stapler or suture.

Gastro-esophageal anastomosis

Figure 1 The automatic pursestringer is placed at site of planned resection, fired and left locked. The esophagus is
transected below the instrument, which is left on to control the esophagus until further dissection is unnecessary and
anvil is to be placed.

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W.A. Koltun

192

Figure 2 Placement of the anvil is facilitated by using a Babcock to grasp the esophagus several centimeters proximal and
one or two Allis clamps to open the cut end of the esophagus.

Gastro-esophageal anastomosis

193

Figure 3 The esophagus is easily retrieved from posterior mediastinum using the secured anvil shaft. It is engaged with
the handheld portion of the circular instrument, having been placed through a gastrotomy downstream of the anastomosis.

Results and Pitfalls

The described technique using the circular stapling device
and automatic pursestringer instruments provides an improved ability to perform a safe esophago-gastric anastomosis
in the tight quarters of the upper abdomen or lower posterior
mediastinum. Various studies and operators have suggested
an improved anastomotic leak rate using the circular stapler,
but this has not been consistent between all studies.1,2 The
use of reinforcing sutures, especially in the context of incomplete donuts found on removal of the instrument is recommended.3,4 The most common postoperative complication is
dysphagia because of anastomotic stricture that is most commonly encountered when the smaller diameter circular stapling instruments, especially 25 mm diameter or smaller are
used. When such occurs, it is usually within a few months
after surgery. However, such strictures are very effectively
managed by postoperative bougenage, often requiring two or
less dilatations.5,6 Some advocate the preferential use of a
smaller sized circular stapler accepting the more easily man-

aged complication of anastomotic stricture postoperatively,

rather than using too large an instrument and dealing with
the potentially lethal complication of anastomotic leak because of esophageal disruption or tearing during surgery.

References
1. Wong J, Cheung H, Lui R, et al: Esophagogastric anastomosis performed
with a stapler: The occurrence of leakage and stricture. Surgery 101:408415, 1987
2. Takeyoshi I, Ohwada S, Ogawa T, et al: Esophageal anastomosis following gastrectomy for gastric cancer: Comparison of hand-sewn and stapling technique. Hepatogastroenterology 47:1026-1029, 2000
3. Muehrcke DD, Donnelly RJ: Complications after esophagogastrectomy
using stapling instruments. Ann Thorac Surg 48:257-262, 1989
4. West PN, Marbarger JP, Martz MN, et al: Esophagogastrostomy with the
EEA stapler. Ann Surg 193:76-81, 1981
5. Muehrcke DD, Kaplan DK, Donnelly RJ: Anastomotic narrowing after
esophagogastrectomy with the EEA stapling device. J Thorac Cardiovasc
Surg 97:434-438, 1989
6. Ferguson CM: Esophagogastrostomy using the EEA stapling instrument.
Am Surg 51:223-225, 1985