Surgical Endoscopy

, Volume 29, Issue 11, pp 3304–3312 | Cite as

Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls

  • Mariko Man-i
  • Koichi SudaEmail author
  • Kenji Kikuchi
  • Tsuyoshi Tanaka
  • Shimpei Furuta
  • Masaya Nakauchi
  • Ken Ishikawa
  • Yoshinori Ishida
  • Ichiro Uyama



A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes.


We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH® ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics.


There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10–306] vs. 15 [5–210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4–10] vs. 4 [2–43] days, p = 0.032), fasting period (5 [3–7] vs. 3 [3–24] days, p = 0.022), and hospital stay (14 [10–47] vs. 11 [6–58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites.


Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.


Stomach neoplasms Laparoscopic distal gastrectomy Delta-shaped anastomosis Complication Staple-line bleeding Endo GIA Tri-Staple 



Laparoscopically assisted distal gastrectomy


Totally laparoscopic distal gastrectomy


ENDOPATH® ETS Articulating Linear Cutters


Endo GIA™ Reload with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler


Creatinine clearance


Eastern Cooperative Oncology Group


American Society of Anesthesiologists


Arterial oxygen pressure


University Hospital Medical Information Network Clinical Trials Registry


Japanese Gastric Cancer Association


Area under the curve



Our “Feasibility Study of Delta-Shaped Anastomosis in Totally Laparoscopic Billroth I Gastrectomy using Tri-Staple” was funded by Covidien Surgical Devices Investigator Sponsored Research Grants (2,100,000JPY), and Koichi Suda and Ichiro Uyama have conflicts of interest and financial ties to disclose. Mariko Man-i, Kenji Kikuchi, Tsuyoshi Tanaka, Shimpei Furuta, Masaya Nakauchi, Ken Ishikawa, and Yoshinori Ishida have no conflicts of interest or financial ties to disclose.

Supplementary material

Supplementary Video clip: Blurring of the stapler tip in the process of firing analyzed with motion analysis software (M4 V 6702 kb)


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Mariko Man-i
    • 1
  • Koichi Suda
    • 1
    Email author
  • Kenji Kikuchi
    • 1
  • Tsuyoshi Tanaka
    • 1
  • Shimpei Furuta
    • 1
  • Masaya Nakauchi
    • 1
  • Ken Ishikawa
    • 1
  • Yoshinori Ishida
    • 1
  • Ichiro Uyama
    • 1
  1. 1.Division of Upper GI, Department of SurgeryFujita Health UniversityToyoakeJapan

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