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Page 4 of 7 Zhang et al. Mini-invasive Surg 2019;3:2 I http://dx.doi.org/10.20517/2574-1225.2018.64

from two intersections to only one as an inverted T-shape, which could decrease the anastomotic weak
point. They reported comparable postoperative outcomes and showed that modified DA was technically
[23]
safe and feasible in another study.
After DA, many surgeons develop many other anastomosis methods based on linear stapler.

Triangulating stapling technique
[24]
Tanimura et al. described the triangulating stapling technique based on a linear stapling device in 2008.
The mean anastomotic time was 35 min. In this method, the duodenum can be transected in any direction,
and by forming a triangle, the anastomosis lumen is made wide with no ischemic areas. Both stumps of
duodenum and remnant stomach were opened fitting their caliber, the gastroduodenostomy linear stapler
in the posterior wall and 2 everted sutures in the anterior wall with linear staplers. Before each direction
anastomosis, both duodenum and remnant stomach were elevated ventrally with 3 stay sutures. But
there are still some problems about this method. There were some differences between the stomach and
duodenum in terms of lumen size, wall thickness, and wall extensibility. The first introverted anastomosis,
which forms the base of the triangle, was cumbersome once all of the staple lines on the stomach and
duodenum had been cut off.

Book-binding technique
[25]
Ikeda el al. described the book-binding technique using linear stapler in 2012. The mean anastomotic time
was 34 min. In their method, the duodenum was transected form the greater curvature side to the lesser
curvature side. Small openings are made in the remnant stomach and duodenal stumps just wide enough to
insert one of the jaws of the linear stapler. After the first stapling, there were three staple lines including those
from the transection of the stomach and duodenum, which ran in parallel to the anterior wall. To prevent
the formation of ischemic areas, a large opening was created on the anterior wall by transecting the entire
duodenal stump and one-third of the gastric stump together with the anterior wall of the first anastomosis
line. The anterior hole was then fired by linear stapler twice to close the large opening. Because a large
opening was created on the anterior wall by transecting tissue and anastomosis line, maybe some tension
was generated after the anterior hole was closed by the linear stapler. Further studies need to be done.

Linear-shaped gastroduodenostomy
[26]
Byun et al. developed a linear-shaper gastroduodenostomy method by which the appearance of
anastomosis was completed inverted T-shaped in 2009. Duodenum was transected from the greater
curvature side to less side. One incision was done in the greater curvature of remnant stomach at the point
60 mm apart from the resected line. The other incision was done on the superior edge of the duodenal
transection line. After creating the c anastomosis lumen, the common entry incision was closed by
laparoscopic linear staplers. Finally, the greater curvature of stomach and the antero-superior of duodenum
were perpendicular. By using this method, the rotation duodenum and remnant stomach was not needed
which can reduce the risk of poor vascular supply. In their study, there were less bile reflux, gastritis degree
and residual food grade compared to DA anastomosis in 6 months after surgery.

Augmented rectangle technique
In our group, we developed a method named augmented rectangle technique (ART) anastomosis. Three
automatic laparoscopic linear staplers were used to create the gastroduodenostomy and the anastomotic
[27]
opening was wide and less likely to become stenosed or twisted . This method was easy and time-saving.
We performed 160 LDG operations using this technique from December 2013 to August 2017. There
were no postoperative complications associated with the reconstruction, such as anastomotic leakage,
hemorrhage or stenosis. In the ART method, the duodenum was transected form the greater curvature
side to less side. Small incisions were made in duodenal stumps and the greater curvature of remnant
stomach in order to insert the jaws of the linear stapler. After inserting the stapler, the lesser curvature