A report is given on 26 patients (18 men and 8 women) undergoing low anterior resection for carcinoma of the rectum, using both the TA 55 and EEA staplers. The average age was 65 years (range, 45 to 92 years). The preoperative level of the lesion from the anal verge averaged 9.8 cm (range, 4 to 17 cm). All had well-differentiated or moderately well-differentiated lesions. All lesions were removed using the following technique. The TA 55 stapler was placed across the lower rectum at the distal resection margin. The EEA stapler was introduced into the rectum with the anvil removed. The shaft was then passed through the rectum stump either through or immediately adjacent to the staple line. The anvil was refitted and the anastomosis completed between the more proximal colon and the rectal stump. A defunctioning colostomy was employed in only one patient. There has been no mortality. Follow-up has been 2 to 16 months, and there has been no early recurrence. The postoperative level of the anastomosis averaged 5.5 cm (range, 2 to 11 cm). Stapler-related complications occurred in three patients. One of these patients developed a postoperative anastomotic leak, which necessitated a defunctioning colostomy. Two anastomotic strictures occurred following either an anastomotic leak or postoperative radiation therapy. Early incontinence to gas, night-time anal soilage, and urgency occurred in eight patients (30 per cent). These symptoms improved or disappeared within three months following operation. The authors' preliminary experience has shown the double stapling technique to have definite advantages. It obviates the use of lower purse-string suture and permits a lower and easier anastomosis. It avoids the problem of disparity of sizes of the two ends of the bowel. The rectum is not opened and fecal spillage is minimized. To date, results have been good without excessive complications.

The double stapling technique (TA-55 and EEA staplers) was used to perform low anterior resections for rectal carcinomas in 79 patients (49 men, 30 women). The mean age was 66 years (range, 38 to 85 years). Curative resections were performed in 68 patients, and palliative resections in 11 patients. The mean level of the cancer from the dentate line was 9 cm (range, 5 to 16 cm). The mean follow-up has been 29 months (range, four to 58 months). Perioperative mortality was 2.5 percent (two patients). Technical problems related to the stapling technique occurred in 6 percent (five patients). The clinical anastomotic leak rate was 8 percent (six patients). There were 11 local recurrences among 68 curative resections (16 percent). Local recurrence according to individual surgeon showed marked variability (range, 0-43 percent, P greater than 0.05). There were no differences in location, differentiation, or stage in those that recurred. The mean distal resection margin for the recurrent cancer group was 3.0 cm and for the nonrecurrent group, 2.9 cm. Disturbances of continence were seen commonly (56 percent) in the first three months after surgery, but 85 percent of patients became fully continent with an acceptable bowel habit at later follow-up. The double stapling technique is useful for the restorative resection of suitable mid and low rectal cancers. The anastomotic leak rate, local recurrence rate, and functional results are acceptable.

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We tested the claim that uni- and multinodular goiter (UNG and MNG) and papillary carcinoma (PC) of the thyroid are autoimmune thyroid diseases (AITD) similar to Graves' disease (GD) and Hashimoto's thyroiditis (HT). The expression of HLA-DR on cultured thyroid epithelial cells (thyrocytes) from UNG, MNG, and PC after coculture with autologous peripheral blood mononuclear cells (PBMC) was compared with that on GD and HT cells. The thyrocytes also were cultured with interferon-gamma (IFN gamma) alone. A cytotoxicity assay involving 51Cr-labeled thyrocytes, anti-HLA-DR, and complement was used to determine HLA-DR expression. Stimulation of thyrocytes with 200 U/mL IFN gamma induced HLA-DR (expressed as a cytotoxicity index) equally well on all thyrocytes [AITD (n = 6): IFN gamma, 23.8 +/- 7.7 (+/- SD); unstimulated, 3.6 +/- 2.0; UNG (n = 6), MNG (n = 9), and PC (n = 5): IFN gamma, 22.5 +/- 4.7; unstimulated, 4.0 +/- 3.0]. When cocultured with autologous PBMC, the values were: AITD, 24.9 +/- 10.1; UNG, MNG, and PC, 3.8 +/- 3.7 (P less than 0.001). The supernatants from the AITD cocultures had higher IFN gamma concentrations (by RIA) than those from the other cocultures. We conclude that in UNG, MNG, and PC, the peripheral blood helper T-lymphocytes are not sensitized to thyrocyte membrane antigen(s); consequently, little if any IFN gamma is produced in cocultures, and hence, there is no increase in thyrocyte HLA-DR expression, unlike the situation in AITD (GD and HT). Thus, UNG, MNG, and PC are not primarily autoimmune in nature, as defined by a lack of sensitization of the PBMC of such patients to thyroid antigen(s).