Circular Stapling Device Research Articles

Exocrine pancreas graft drainage in recipient duodenum through side-to-side duodeno-duodenostomy

The interesting report by Hummel et al. in the Februaryissue of this Journal [1] confirmed our previouspublication indicating that, in pancreas transplantation,side-to-side duodeno-duodenal anastomosis is technicallyfeasible and allows easy access to the graft duodenalmucosa for repeated biopsies and rejection monitoring[2]. In our experience we prefer to anastomose the graftportal vein to the infrapancreatic superior mesenteric veinsimilarly to the technique described by Boggi et al. [3].With this procedure, the pancreas graft is positioned in apure retroperitoneal and physiologic location for bothendocrine and exocrine drainage, but it is uncertain ifthis fact has any influence on the functional results of thetransplantation.The main drawback of this technique is the potentialfor anastomotic leak that could be challenging to controlas the recipient duodenum cannot be resected. Directduodenal repair, plasty with a Roux-en-Y limb, orlaterolateral duodenojejunostomy may be surgical optionsto achieve recipient duodenal closure in case of anasto-motic leak [2].We considered using this technique in our last fivepancreas transplantations (three pancreas alone and twosimultaneous pancreas-kidney transplantations). In fourpatients, side-to-side duodeno-duodenal anastomosis wasperformed (three manually and one with a circularstapling device, according to the surgeon’s preference).Immunosuppression consisted of quadruple therapy,including induction with polyclonal antibodies andmaintenance with tacrolimus, mycophenolate mofetil andlow-dose steroids. These patients underwent regularprotocol duodenal biopsies, without any evidence of acuteor chronic rejection. Pancreas graft and patient survival is100% at follow-up. One patient required two re-laparoto-mies, for early non-infected peripancreatic hematoma andfor late (>6 months) mechanical intestinal occlusion. Nopatient experienced any complication linked to theduodenal anastomosis or to the vascular reconstruction.In the fifth patient recipient of simultaneous pancreas-kidney transplantation, pancreas graft duodenum wasfound to be badly preserved at reperfusion, and we thenchose to perform duodenal drainage through a Roux-en-Y jejunal limb. This patient developed anastomoticleakage requiring life-saving pancreas graft resection afterthree unsuccessful attempts of surgical correction.This small series of duodeno-duodenal drainage ofpancreas grafts, and the case described by Hummel,provide some evidence that this technique is feasible,appears to be safe in pancreas grafts with good duodenalpreservation, and provides easy access of the duodenalmucosa for rejection monitoring. All these pancreas graftsare functioning perfectly and did not develop any episodeof rejection. These promising results need to beconfirmed by larger series and controlled comparisonwith classical enteric drainage.Arnaud De Roover, Olivier Detry,Carla Coimbra, Jean-Paul Squifflet,Pierre Honore´ and Michel MeurisseDepartment of Abdominal Surgeryand Transplantation,University of Liege,Liege, Belgium

Division of the Small Bowel with the LigaSure Atlas Device During the Right Laparoscopic Colectomy

Bowel division and anastomosis were facilitated greatly with the advent of stapling techniques. Since then, there have not been any new evolving technologies to facilitate these maneuvers. For this reason, we recently applied the LigaSure Atlas device (Valleylab, Boulder, CO) to the division of the small bowel during this procedure to obtain a reliable and low-cost division of the ileum. After vessel ligation and ileocolic mobilization, the terminal ileum is sealed and divided with the LigaSure Atlas. This device is applied sequentially along the small bowel twice to ensure an adequate seal before the cut. A terminolateral ileotransversostomy is performed extracorporeally with a mechanical circular stapling device, installing the anvil of the circular stapler into the ileal stump. We have not encountered any problems with this technique since its introduction in our institution, and no leakage or bursting of the ileal stumps. This technique enables an easy, reliable, and inexpensive technical option to optimize the right laparoscopic colectomy procedure.

Intracorporeal Billroth 1 Reconstruction by Triangulating Stapling Technique After Laparoscopic Distal Gastrectomy for Gastric Cancer

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

NICE Technology Appraisal on Stapled Haemorrhoidopexy for the Treatment of Haemorrhoids

This article outlines the recommendations, the clinical and cost-effectiveness evidence and the Appraisal Committee's considerations for the recently published NICE technology appraisal on stapled haemorrhoidopexy for the treatment of haemorrhoids.1 Estimates of the proportion of the UK population affected by haemorrhoids range from 4.4–24.5%. In 2004–2005, approximately 23,000 procedures listed as ‘main operations on haemorrhoids’” were performed in England and Wales. Haemorrhoids are classified as ‘first-degree’ if they bleed but do not prolapse; second-degree haemorrhoids prolapse during bowel movements, and reduce spontaneously; third-degree haemorrhoids prolapse on straining and require manual reduction; fourth-degree haemorrhoids prolapse and cannot be manually reduced. Surgery is the usual treatment for third and fourth degree haemorrhoids that have not responded to non-surgical interventions and for full circumferential second degree haemorrhoids. The most commonly conducted surgical techniques are the Milligan–Morgan or Ferguson haemorrhoidectomy. The Milligan–Morgan procedure involves dissection of the haemorrhoid and ligation of the vascular pedicle with the wounds being left open to heal naturally. Healing is frequently delayed, which may result in discomfort and prolonged postoperative morbidity. The Ferguson procedure is a modified version of the Milligan–Morgan technique, in which the wound is closed with a continuous suture to promote healing. Another, less frequently used procedure is the Parks submucosal haemorrhoidectomy, which uses intra-anal incisions directly over each haemorrhoid, with the underlying haemorrhoidal tissue excised. Stapled haemorrhoidopexy is a technique that reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosal membrane above the dentate line, using a specially designed circular stapling device. This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. Stapled haemorrhoidopexy has been carried out in the UK for the last 2–3 years.

A Novel Technique to Relieve a Closed-Loop Obstruction Secondary to a Competent Ileocecal Valve and an Unresectable Mid-Colon Tumor

A competent ileocecal valve complicates the surgical treatment of an unresectable obstructing mid-colon tumor. Specifically, it may not be feasible to bypass with a colocolotomy, especially when the sigmoid colon has limited mobility or if the ascending colon is severely distended and edematous. A technique is described in which the closedloop obstruction is relieved at its proximal extent by an ileocecal valvuloplasty. A circular stapling device is fired across the ileocecal valve. Once the ileocecal valve is rendered competent, a loop ileostomy or a colocolotomy can be constructed, providing effective palliation for this difficult situation.

Transanal Treatment of Strictured Rectal Anastomosis with a Circular Stapler Device: Simple and Safe

Background: Several methods of treatment for benign anastomotic strictures after low anterior resection have been described. We report and illustrate a simple, safe, and effective method for treating benign rectal anastomotic strictures by means of a transanal circular stapling device. Methods: Three patients with a clinically significant rectal stricture underwent transanal resection of the fibrous stenosis by a circular stapler device (CEEA stapler 29 or 31 mm calibre; Tyco Co., USA). Results: No complications occurred. Patients were discharged from the hospital on the first postoperative day. After a follow-up period of 8, 12 and 14 months respectively, no recurrence of the stricture was observed. The stool habits of all 3 patients were normal with 1–3 formed, asymptomatic fecal passages per day. Conclusion: Transanal reanastomosis by means of a circular stapler device is a simple and effective method. However, a larger number of patients need to be treated with this relatively new method to draw further conclusions.

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

The technique and results of laparoscopic gastrectomy in 110 patients with gastric cancer located in the upper third of the stomach are presented. Proximal gastrectomy was performed for lesions in the upper third of the stomach, and total gastrectomy for those that spread over both the upper and middle third. D1 and D2 lymph node dissection was undertaken in patients with T1 or T2 lesions. Anastomosis of the oesophagus was performed intracorporeally using a conventional circular stapling device or a laparoscopic linear stapler. Median operating time was 247 min for proximal gastrectomy and 285 min for total gastrectomy; median blood loss was 207 and 334 ml respectively. A median of 23 lymph nodes was harvested from patients in the proximal gastrectomy group and 34 from those having a total gastrectomy. There was minimal morbidity and fast recovery after surgery. Postoperative recurrence occurred in only one patient, giving a recurrence rate of 0.9 per cent. Laparoscopic gastrectomy for upper gastric cancer appears to be a safe and curative procedure.

Stapled versus conventional surgery for hemorrhoids

Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques. This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids. We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009. All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included. Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model. Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

Laparoscopically assisted total gastrectomy with jejunal pouch interposition

Jejunal pouch interposition (JPI) is known as a useful gastric replacement procedure after total gastrectomy. The JPI procedure, however, has not been applicable to laparoscopically assisted total gastrectomy (LATG) because of its technical complexity and difficulty. This study aimed to describe our modified LATG/JPI technique, and to evaluate its feasibility, safety, and early postoperative functional outcome. Between September 2002 and August 2003, LATG/JPI was attempted for five patients (3 men and 2 women) with early gastric cancers in the upper portion of the stomach. The mean age of the patients was 57 years, and their BMI was 21 kg/m2. Using a 5-port technique, the gastric arteries were laparoscopically clipped and divided with adequate lymphatic dissection. After completion of gastric resection, the anvil of a circular stapling device was placed in the esophageal stump. An 8-cm minilaparotomy then was performed, and the 12-cm pouch was created extracorporeally in the "reverse U" fashion. The stapled pouch-esophagostomy was performed under laparoscopic monitoring. The remainder of the procedure was accomplished under direct vision. All cases were managed laparoscopically without any complications. The mean operating time was 407 min, and the blood loss was 279 ml. All the patients showed rapid and uneventful recovery. Postoperative studies, including dual scintigraphy, showed that all jejunal pouches were satisfactorily functioning. This study showed LATG/JPI to be feasible and safe. With technical modifications, LATG/JPI can become a potentially effective option for improving patients' quality of life after total gastrectomy.

Experimental Study of Aortic Anastomosis Using a Circular Stapling Device in the Porcine Model

Objectives The aim of this study was to assess the strength (pressure resistance) and histological findings of aortic anastomoses performed using a circular stapling device. Materials and methods A circular stapling device was used for anastomosing a porcine aorta and a Dacron graft. The maximum pressure resistance of the anastomotic site of a porcine aortic specimen and a Dacron graft was examined ( n=10). A porcine aorta with Dacron graft was anastomosed to a beating heart, and pressure overload was induced by adrenaline ( n=5). Specimens of the anastomotic sites were harvested after 14 days and examined histologically. Results The maximum pressure resistance of the anastomotic site was 427.3±34.4 (375–511) mmHg. No anastomotic sites leaked as a result of pressure overloading at 227.6±21.1 (201–260) mmHg. Histologically, good incorporation and cell coverage were observed, and the inner surfaces of the anastomotic sites were smooth and without stenoses. Conclusions Aortic anastomosis using a circular stapling device is feasible and worthy of further investigation.

繰り返す痔瘻・肛門周囲膿瘍により生じた高度肛門狭窄に対し, circular staplingが有効であった1例

繰り返す痔瘻・肛門周囲膿瘍により生じた高度肛門狭窄に対し, circular staplingが有効であった1例

Five years' experience in stapling the oesophagus and rectum.

In the 5-year period from 1976 to 1980, 143 anastomoses were performed using circular stapling devices. In 2 further cases, anastomosis was attempted but failed and operation was completed by orthodox methods. There were 101 oesophageal anastomoses; 70 of these were transections in patients with oesophageal varices and 31 were either oesophagogastric or oesophagojejunal in nature, mainly following excisional cancer surgery. The remaining 42 patients had colorectal anastomoses following anterior resection of the rectosigmoid. Initial results in a follow-up period from 2 months to 5 years have been encouraging. There were 3 cases of complete anastomotic dehiscence and 4 cases of leakage. Stricture formation occurred in 10 per cent of patients but was easily controlled in the majority of cases.

Use of circular stapling gun with peranal insertion of anorectal purse-string suture for construction of very low colorectal or colo-anal anastomoses

A technique is described for construction of the colorectal or colo-anal anastomosis in low rectal resection by using an automatic circular stapling device and inserting the anorectal purse-string suture peranally from below. This method was employed in 4 patients resulting in complete healing in 3 cases and a moderate leak in 1, which, however, eventually healed satisfactorily.

Cervical esophagogastric anastomosis with a new stapler in the surgery of esophageal carcinoma

A new reusable circular stapler for cervical esophagogastric anastomosis (CEGA) has been used to substitute the traditional method of hand-sewn cervical anastomosis. Over a 2-year period (09/1998-11/2000), the stapler was engaged on operations of 112 patients with thoracic esophageal carcinoma, and the anastomosis was performed through both cervical and thoracic incision. The operative approaches were through left thoracotomy in 85 cases, and through right thoracotomy in 27 cases. The results were analyzed retrospectively. All of the 112 CEGA operations were successfully performed on the patients who underwent esophageal resections, and no operative mortality and anastomotic leakage occurred. Excluding the two patients with the anastomotic recurrent carcinoma, anastomotic stricture occurred in 12 cases (10.9%, n=110). Median time to the presentation of anastomotic stricture was 4.3 months (range 2.6-25.3 months), and the median number of dilatations was 3 (range 1-5). When divided into the 24 and 26 mm groups, the respective incidences of stricture were 12.3 (7/57) and 9.4% (5/53), respectively, and the statistical results of the two sizes of staplers were essentially the same (P=0.6691). Eight patients experienced nonanastomotic-related complications (7.3%, n=110), in which there were three cases of recurrent laryngeal nerve injury, four cases of the left side pneumothorax, and one case of perforation of the proximal stomach. There was also a case of stapling gauze at anastomosis. Some of the complications were closely related to the initially improper use of the new stapler's craft. The results indicate that CEGA using the new circular stapling device in surgery of the esophageal carcinoma is a very effective procedure to improve the anastomotic technique from a traditional hand-sewn anastomosis to a stapled anastomosis and can reduce the incidence of complications.

Day case stapled haemorrhoidopexy for prolapsing haemorrhoids

Conventional surgical management of prolapsing haemorrhoids is by excisional haemorrhoidectomy. Postoperative pain has restricted the application of such procedures in the day case setting. These operations remain associated with a period of restricted activity. The use of circular stapling devices as an alternative to the excisional approach in the management of haemorrhoids has been described. This study reports our experience of stapled haemorrhoidopexy as a day case procedure. Patients with third or fourth degree haemorrhoids were eligible for the procedure. Patients were considered suitable candidates for day case surgery based on conventional parameters. Symptoms were assessed using a previously validated symptom severity rating score. Stapled haemorrhoidopexy was carried out using a circular stapling device. Pain scores were obtained prior to discharge. Patients were admitted if pain was uncontrolled despite oral analgesia. Symptoms were re-scored at six-week follow-up. Over a 70-month period 168 consecutive stapled haemorrhoidopexies were performed or directly supervised by one consultant colorectal surgeon. One hundred and ten (65%) patients were considered appropriate candidates for day case surgery by conventional criteria. Ninety-six (87.3%) patients successfully underwent stapled haemorrhoidopexy on a day case basis. Fourteen (12.7%) patients required admission on the day of surgery (5 for early postoperative bleeding, 4 for pain necessitating continuing opiate analgesia, two for urinary retention and three for surgery performed late in the day). Six (5%) patients were re-admitted postoperatively; four for pain relief and two because of urinary retention. Of the day case patients, 91 (82.7%) and 56 (50.9%) had been seen for 6 week and 6 month review, respectively, at the time of analysis. Symptom scores were 6 (pre-operatively) vs 0 (postoperatively) (P < 0.01). 76/91 (83.5%) patients reviewed at 6/52 were asymptomatic. Stapled haemorrhoidopexy is a safe and effective procedure that can be carried out on selected patients on a day case basis. Complications are of a similar nature to excisional haemorrhoidectomy.

A simple technique for circular-stapled Billroth I reconstruction in laparoscopic gastrectomy

A simple surgical technique that facilitates circular-stapled Billroth I gastroduodenostomy in laparoscopic distal gastrectomy is described. After standard laparoscopic mobilization of the distal stomach, a small duodenotomy is made just distal to the pyloric ring. The anvil of a circular-stapling device, secured with a Vicryl suture, is introduced via the duodenotomy. The Vicryl suture is advanced anteriorly so that a center rod penetrates the anterior duodenal wall. The duodenum is staple-transected at this point, and the center rod is wrapped with the stapled duodenal stump by approximation of both edges using a suturing device. The circular-stapled gastroduodenostomy then is completed in a standard fashion. The authors have used this technique for three patients, and their early outcomes are promising.

The Strictured Anastomosis: Successful Treatment by Corticosteroid Injections—Report of Three Cases and Review of the Literature

Clinically significant anastomotic strictures usually only occur with very low colorectal anastomoses below the level of the peritoneal reflection. The reported rate averages 8 percent and has been attributed to tissue ischemia, localized sepsis, anastomotic leak, proximal fecal diversion, radiation injury, inflammatory bowel disease, and recurrent rectal cancer. Most patients will have symptoms of obstipation, frequent small bowel movements, and bloating. Symptomatic strictures are often approached by dilation (balloon or Hegar) or less often repeat resection. Many of these patients have anastomoses that are too low to consider repeat resection. Strictureplasty with linear stapling devices, stricture resection by use of the circular stapling device, and repeat dilations have all been described. Steroid injections into the stricture have been described in strictured esophagogastric anastomoses but have not been commonly used for strictured coloproctostomies. We describe three cases of coloanal stricture following resections that were complicated by postoperative pelvic abcesses, anastomatic leaks, and pelvic fibrosis. Two cases had undergone low coloanal anastomosis that was protected by a loop ileostomy and developed as significant stricture in the early postoperative period. The third case was managed without a protective loop ileostomy. These were initially managed by repeated dilation of the anastomosis. Each episode was followed by rapid recurrence of the stricture. All patients underwent subsequent dilation with injection of 40 mg of triamcinolone acetate (divided dose in four quadrants) into the stricture and subsequent complete resolution of the stricture. Those patients with loop ileostomies had them taken down and all have been followed for up to 12 months without clinical or endoscopic evidence of recurrent stricture.

Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles

The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure. Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients. Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique. Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.

Circular vascular stapling in coronary surgery

Stapling devices have been clinically applied to connect blood vessels. The early application of these staplers in cardiovascular surgery, including coronary bypass surgery, was encouraging. With further refinement of suture material, however, vascular staplers became impractical and soon fell into oblivion. With advancement in robotic surgery, these devices might become valuable tools once again. Herein early experience with vascular circular stapling devices is reviewed.

The circular stapling device as a risk factor for anastomotic leakage.

To investigate the relation between the type of circular stapler and anastomotic leak in rectal cancer surgery. During the past decades results from rectal cancer surgery have improved considerably regarding risk of local recurrence and survival. Two main paradigm changes are considered to be the cause for this: the introduction of total mesorectal excision (TME) and the increasing use of radiotherapy. However, rectal cancer surgery is associated with an unacceptably high frequency of complications of which anastomotic leak is one of the most severe ones. The hypothesis was raised that the choice of stapler influenced the leakage rates. A questionnaire was sent to all departments of surgery (n = 66) performing rectal cancer surgery in Sweden to determine the choice of circular stapler when performing anterior resection for rectal cancer. These data were linked to the Swedish Rectal Cancer Registry for the period 1995-99. A total of 3316 patients had an anterior resection. The choice of circular stapling device was determined in 70% of the cases. When stapler A was used, the leakage rate was 11% whereas it was 7% when stapler B was used (P = 0.0039). In the cases where it was impossible to determine which stapler had been used the leakage rate was 8%. Quality control is an important part of medicine and the present study suggests that it also must include surgical instruments. A prospective randomised study is needed to confirm the results.