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Alternatively, some prefer to introduce the circular stapler (EEA) into the open distal end of the stomach (Figure 7) and direct the rod through the center of a previously placed purse-string suture in the posterior gastric wall approximately 3 cm from the proposed line of resection. The duodenal opening is checked with a sizing instrument; the 28-mm circular stapler (EEA) is most commonly used. The cap is applied to the rod, and it is introduced into the open end of the transected duodenum (Figure 8). The monofilament polypropylene purse-string suture around the duodenal wall is tied tightly (Figure 9). The anvil and cap are approximated and the instrument is fired. The stapler is opened and then gently rocked back and forth and the line of staples stabilized with one hand as the tilted head of the instrument is slowly removed. Additional interrupted sutures may be indicated about the staple line (Figure 10). The posterior wall of the stomach may be opened longitudinally for a short distance to obtain better visualization of the suture line. Thereafter, the noncutting linear stapler (TA 90) with the longer gastric staples is applied to transect the avascular distal antrum of the stomach (Figure 11). This may be the preferred method, since the anterior-wall suture line created by the gastrotomy for introduction of the stapler is avoided (Figure 12).

A small nasogastric (NG) tube may be inserted for decompression and later feedings. The incision is closed in a routine manner.

Daily weight, fluid, and electrolyte measurements are recorded until the patient is taking adequate fluids and nutrition by mouth. Clear liquids are permitted on the first postoperative day. Oral intake should be restricted if there is a feeling of fullness or if vomiting occurs. Measurement of gastric output or residuals after the NG tube is clamped for 4 hours may be useful in timing the restart of oral intake. Six daily small feedings with limitation of sweets and milk may be helpful for several weeks.

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