194 I . S. Fentiman et al.

References 1. Stoll B. A. and Ellis F.: Treatment by oestrogens of pulmonary

metastases from breast cancer. Er. Med. J . 1953; 2: 796-800. 2. Porter E. H.: Pleural effusion and breast cancer. Br. Med. J . 1965;

3. Abrams H. L., Spiro R. and Goldstein N.: Metastases in carcinoma. Cancer 1950; 50: 74-85.

4. Warren S. and Witham E. M.: Studies on tumor metastasis. 2. ?he distribution of metastases in cancer of the breast. Surg. Gynecol. Obstet. 1933; 57: 81-5. Fentiman I. S., Millis R., Sexton S. et aI.: Pleural effusion in breast cancer. Cancer 1981; 4 7 7087-92.

1: 251-2.

5.

Paper accepted 30 September 1981.

resulted from lymphatic obstruction. In those cases in which malignant cells were seen cytologically, their presence may have resulted from subsequent colonization by an ascitic form of metastatic tumour cell.

Pleural effusion secondary to breast cancer is unlikely to have a unifactorial aetiology. It is conceivable that in some patients, changes in capillary permeability due to the presence of blood-borne malignant cells may act in association with obstruction of lymph flow due to direct invasion of lymphatic pathways by tumour cells. In other patients, only one factor may independently be responsible. Further clarification may eventually enable more rational treatment of pleural effusions in individual patients with metastatic breast cancer.

Br. J. Surg. Vol. 69 (1982) 194 Printed in Great Britain

A modification of the EEA autosuture device

Patrick Gallagher and Philip F. Schofield University Hospital of South Manchester, Net1 lane, West Didsbury, Manchester 20

The EEA autosuture device has proved a useful instrument, especially in low anterior resection of the rectum (1). Nevertheless, we have reported complications, including narrowing of the anastomosis ( 2 ) . We feel, therefore, that all colonic anastomoses should be made as wide as possible using the largest cartridge head. When the proximal colon is narrow, it may be difficult to thread it onto the device ( 2 ) , the protruding large knurled nut on the anvil being the main cause of difficulty. We have modified the autosuture device to overcome this problem.

Modijication The knurled nut fits onto the screw end of the standard instrument to afix the anvil. This has been removed and replaced by a nut which is recessed into the anvil and tightened by a special key (Fig. 1). The smoother shorter new anvil allows easier engagement of the proximal bowel end (Fig. 2 ) . Rather

than the anvil being inserted end-on into the bowel lumen, it is now inserted sideways and, without the knurled nut, the bowel may be easily slid over.

Discussion We have used the new anvil in both in vitro and in vivo anastomoses and have found that it functioned well in every case. With this modification, it is never necessary to use anything less than the largest size cartridge for any colonic anastomosis.

References 1. Heald R. J.: Towards fewer colostomies-the impact of circular

stapling devices on the surgery of rectal cancer in a district hospital. Br. J . Surg. 1980; 67: 201-2. Cade D., Gallagher P., Schofield P. F. et al.: Complications of anterior resection of the rectum using the EEA stapling device. Er. J . Surg. 1981; 68: 339-40.

Paper accepted 14 August 1981.

2.

Fig. 1. Lower left, unmodified anvil with protruding knurled nut; lower right, modified anvil with recessed nut; above, instrument .for tighten- ing recessed nut.

Fig. 2. The modijication of the EEA circular stapler showing,from right to left. modified anvil with recessed nut. gap to accept bowel ends and cartridge enclosing knife and staples.