Accepted Manuscript A New Technique for Shaping the Gastric Tube, Using Both Radial and Linear Staplers Masahiro Kimura , MD, PhD Yoshiyuki Kuwabara , MD, PhD Hideyuki Ishiguro , MD, PhD Takuya Ando , MD, PhD. Ryo Ogawa , MD, PhD. Midori Shiozaki , MD, PhD. Tatsuya Tanaka , MD, PhD. Hiromitsu Takeyama , MD, PhD PII:
S1072-7515(14)00382-2
DOI:
10.1016/j.jamcollsurg.2014.01.067
Reference:
ACS 7392
To appear in:
Journal of the American College of Surgeons
Received Date: 9 December 2013 Accepted Date: 22 January 2014
Please cite this article as: Kimura M, Kuwabara Y, Ishiguro H, Ando T, Ogawa R, Shiozaki M, Tanaka T, Takeyama H, A New Technique for Shaping the Gastric Tube, Using Both Radial and Linear Staplers, Journal of the American College of Surgeons (2014), doi: 10.1016/j.jamcollsurg.2014.01.067. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A New Technique for Shaping the Gastric Tube, Using Both Radial and
RI PT
Linear Staplers
Masahiro Kimura, MD, PhD., Yoshiyuki Kuwabara, MD, PhD., Hideyuki Ishiguro,
SC
MD, PhD., Takuya Ando, MD, PhD., Ryo Ogawa, MD, PhD., Midori Shiozaki, MD,
M AN U
PhD., Tatsuya Tanaka, MD, PhD., Hiromitsu Takeyama, MD, PhD.
Gastroenterological Surgery, Nagoya City University Graduate School of Medical
TE D
Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
Correspondence address: Masahiro Kimura, Gastroenterological Surgery, Nagoya
EP
City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho,
AC C
Mizuho-ku, Nagoya 467-8601, Japan e-mail: [email protected]
Disclosure Information: Nothing to disclose. Short Title: Shaping the Gastric Tube Using Staplers
1
ACCEPTED MANUSCRIPT
One factor influencing surgery for esophageal cancer is the reconstruction technique, which may involve constructing a tube from the stomach or the intestines. Good blood
RI PT
flow and adequate length are necessary (1). Gastric tube formation became easier with the availability of improved surgical staplers, but gastric tube necrosis and leakage may
SC
still occur. Therefore, a simple technique providing good blood flow to the end of the
M AN U
gastric tube is needed. One method is called whole stomach: the surgeon excises the small part of the gastric wall supplied by the left gastric artery (2,3). Another is called the gastric tube: the surgeon divides the stomach from the lesser curvature along the axis of the greater curvature. But the gastric tube method is so difficult that various
TE D
devices are used in each institution.
We use the gastric tube method, except in patients with gastric cancer or patients
EP
with a history of gastrectomy. One reason for choosing this method is that it provides
AC C
sufficient length. Length is never a problem, even in the case of the laryngo-esophagotomy. With a linear cutting-stapler, shaping the gastric tube is comparatively easy and time-saving. Since 2012, we have used the Endo-GIATM60 with Tri-StapleTM (Covidien Japan, Tokyo). To shape a long, slender tube, we usually use 6 or 7 linear staplers. The first problem is an irregular section of a knot, which causes no trouble if the serial stapling is in the same direction (Fig. 1). But once the direction
2
ACCEPTED MANUSCRIPT
shifts, inserting a linear stapler becomes difficult, and the knot becomes more notched. To shape a long tube, the angle of the first 2 staplers must be nearly a right angle. If the
RI PT
area below is the remaining side, the section is more notched. These sides are vulnerable with limited blood flow. Therefore, we developed a new technique using two types of
SC
staplers.
M AN U
Technique
We describe two methods: method A and our new procedure, method B. In both methods, the stapler was fired as often as needed to divide the stomach from the lesser curvature along the axis of the greater curvature, creating a 3- to 5-cm wide tube. The
TE D
distance between the incision and the pylorus was approximately 5 cm, where the third branch of the right gastric artery was preserved.
EP
Method A (Fig. 2): The first incision with the linear stapler was toward the
AC C
direction of the greater curvature, near the right angle of the lesser curvature. About 3 cm of the gastric wall was separated by this firing, and an area 3- to 5-cm from the greater curvature was preserved. The next staplers were set parallel to the greater curvature and fired to the cardia, so the angle of the first 2 staplers became nearly 90°. We always use six or seven staplers, 60 mm long, reinforcing the intersections with Albert and Lembert sutures, being especially careful at point b.
3
ACCEPTED MANUSCRIPT
The problems with method A are: •
Once the first stapler is set perpendicularly, it is difficult to insert the second stapler
•
RI PT
parallel to the greater curvature. The staplers overlap at the intersection.
Because of the difficulty in inserting the second stapler, we must twist the gastric
SC
wall, so the section becomes uneven. Frequently, we cannot use the stapler’s full length.
•
We must reinforce the intersections. Because of low blood flow, we always bury this
M AN U
•
intersection.
Method B (Fig. 2, dotted line): We use the GIATM Radial Reload (Covidien,
TE D
Tokyo, Japan) for the first stapler, which places three curved rows of staples 60 mm in length on each side of a cut line and simultaneously divides the tissue between the third
EP
and fourth lines (4). With this stapler, we cut the gastric wall to the estimated
AC C
gastric-tube width. Then, a linear stapler can be set tangential to the arc of the separated line. After the second stapling, we always use three or four staplers 60 mm long. To perform this method more easily and certainly, we developed a special ruler to determine 3 points. First, we mark the initial point about 5 cm from the pylorus (Fig. 3, point a). Point a was placed on a line, at the beginning of one-quarter of a circle (Fig. 4, X-Y), and the line Y-Z was parallel to and a distance of 3- to 5-cm from the greater
4
ACCEPTED MANUSCRIPT
curvature. The intersection of the end of the quarter-circle and the line Y-Z was marked (Fig. 3, point b). Point c was marked on the line Y-Z (Fig. 3), 6 cm from point b. The
RI PT
ruler was removed, and stapling was started. The GIATM Radial Reload was set on the gastric wall. The stapler tip was point b, and point a was on the stapler line. The stapler
SC
was then closed, fired, and removed. Next, the linear stapler, Endo GIA Tri-Staple 60
M AN U
was introduced from the edge of the first separation and fired. Then, we gripped the stomach with no slack and shaped the gastric tube as in method A. We do not extend the gastric wall at the time of stapling. Expansion of the gastric wall causes the transformation post-stapling. Depending on the staple size, the length of the separated
TE D
wall was often shorter than planned, mainly due to stretching caused by the stapler pressure.
EP
With method B, all of the prior problems were solved. Insertion of the second stapler became easier, and overlap of the staples decreased.
•
We do not twist the gastric wall at the time of stapler insertion, and the section
AC C
•
became linear. •
We can use the stapler’s full length. We used two linear staplers to cut from points a to c in method A, but only one with method B.
•
The intersection of the two staplers is similar to the intersection of two linear
5
ACCEPTED MANUSCRIPT
staplers with the same direction, so we omit the Lembert suture. Although the staple line length with method A is longer than with method B,
RI PT
reinforcement sutures shorten the staple line. Due to the staplers’ overlap, the staple line of method A will not become straight; additionally, the staple line (b–c) often becomes
SC
irregular because of twisting the gastric wall, and it will be shortened.
M AN U
With method B, the best direction of the second stapler is Y to Z, but we sometimes must select the direction toward the lesser curvature. Correction takes place on the third stapling or later. A correction of direction 20°, the modification of the staple line and the crush of the intersection
TE D
becomes notable. To avoid these problems, we often use the GIA Radial Reload again. Discussion
EP
Owing to the development and improvement of surgical staplers, suturing and
AC C
anastomosis of the digestive organs, such as during gastric tube reconstruction and esophagectomy, have become easier and safer. Many reports about the methods and experiments for esophageal reconstruction have been made (5). Important conditions required for reconstruction are good blood flow and sufficient length. The gastric tube’s blood supply is from the right gastric artery and gastroepiploic artery, and the blood flow of the gastric wall is decreased to the cardia. Blood flow within the stomach wall is
6
ACCEPTED MANUSCRIPT
also important. To preserve the blood flow within a wall, the whole stomach method is used. It is very easy to shape the whole stomach using one or two linear staplers.
RI PT
Linear staplers are also used to shape the gastric tube. We use the Endo GIA Tri-Stapler because of good operating characteristics and good arrest of hemorrhage. We
SC
usually use a vascular/medium cartridge with 2 mm, 2.5 mm, and 3 mm staples. With
M AN U
this cartridge, no bleeding was found at the staple line’s surface. With a narrow width, continuous stapling became easy, but the problem of the intersection remained. Rapidly turning the stapler must be avoided. Combinations of linear staplers cannot address this problem. The Radial-Reload can cut deeply with a curved line to the planned width.
TE D
Then, linear staplers can cut the gastric wall parallel to the greater curvature. In order to make a series of staplings more simply and smoothly, unification of the first and second
EP
stapler is necessary. Our specialized ruler made it possible to unify the two staplers.
AC C
After three points are decided, stapling is performed. The ruler’s slit facilitates selecting the second stapler’s direction. We have experienced an angle of ≤20° with continuous stapling. When the angle
becomes >20°, cutoff stump modification is required, and the intersection becomes large. With careful stapler insertion, we cannot discover the intersection easily. Moreover, the Radial-Reload is used not only for the first stapling but for closing the
7
ACCEPTED MANUSCRIPT
top of the gastric tube, for the esophagus and gastric anastomosis. We developed a special ruler to assist with a new method of gastric tube formation. Creating a long
RI PT
gastric tube parallel to the greater curvature, an arc about the stomach, is difficult, and it is very difficult to correct the tube’s shape before separating the stomach. With our ruler,
SC
we can make a simple and smooth gastric tube using a radial stapler together with a
M AN U
linear stapler.
REFERENCES 1.
Jean-Mare N, Abdarrahmane D, Assane N, et al. Arteriography of three models
TE D
of gastric oesophagoplasty: the whole stomach, a wide gastric tube and a narrow gastric tube. Surg Radiol Anat 2006;28:429-437.
Zhang MQ, Wu QC, Li Q, et al. Comparison of the health-related quality of life
EP
2.
AC C
in patients with narrow gastric tube and whole stomach reconstruction after oncologic esophagectomy: a prospective randomized study. Scan J Surg 2013;102:77-82. 3.
Collard JM, Tinton N, Malaise J, et al. Esophageal replacement: Gastric tube or
whole stomach? Ann Thorac Surg 1995;60:261-7. 4.
Rivadeneira DE, Verdeja JC, Sonoda T. Improvement access and visibility
during stapling of the ultra-low rectum: a comparative human cadaver study between
8
ACCEPTED MANUSCRIPT
two curved staplers. Ann Surg Innov Res 2012;13:1164-6. Kawano T, Toshino K, Endo M. Cervical esophagogastric anastomosis by the
AC C
EP
TE D
M AN U
SC
cuff technique using a stapler. J Am Coll Surg 1996;183:157-9.
RI PT
5.
9
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Schema of separation of the gastric wall with a linear stapler
RI PT
(A) Line of incision between rows of staplers. (B1-C1) The serial stapling is in the same direction
Fig. 2. The separation direction. Method A indicated by straight arrows
Fig. 3.
Surgical view.
TE D
Method B indicated by the dotted line
M AN U
↑↑↑ = staplers overlap each other at the intersection
SC
(B2-C2) The direction of the stapling has shifted
(A) The ruler and the three selected points.
EP
(B) Curved stapler was set.
AC C
(C) Curved stapler was fired.
(D) Linear stapler was fired next to the curved stapler Fig. 4. Ruler for the gastric tube.
10
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1072-7515(14)00382-2
DOI:
10.1016/j.jamcollsurg.2014.01.067
Reference:
ACS 7392
To appear in:
Journal of the American College of Surgeons
Received Date: 9 December 2013 Accepted Date: 22 January 2014
Please cite this article as: Kimura M, Kuwabara Y, Ishiguro H, Ando T, Ogawa R, Shiozaki M, Tanaka T, Takeyama H, A New Technique for Shaping the Gastric Tube, Using Both Radial and Linear Staplers, Journal of the American College of Surgeons (2014), doi: 10.1016/j.jamcollsurg.2014.01.067. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A New Technique for Shaping the Gastric Tube, Using Both Radial and
RI PT
Linear Staplers
Masahiro Kimura, MD, PhD., Yoshiyuki Kuwabara, MD, PhD., Hideyuki Ishiguro,
SC
MD, PhD., Takuya Ando, MD, PhD., Ryo Ogawa, MD, PhD., Midori Shiozaki, MD,
M AN U
PhD., Tatsuya Tanaka, MD, PhD., Hiromitsu Takeyama, MD, PhD.
Gastroenterological Surgery, Nagoya City University Graduate School of Medical
TE D
Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
Correspondence address: Masahiro Kimura, Gastroenterological Surgery, Nagoya
EP
City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho,
AC C
Mizuho-ku, Nagoya 467-8601, Japan e-mail: [email protected]
Disclosure Information: Nothing to disclose. Short Title: Shaping the Gastric Tube Using Staplers
1
ACCEPTED MANUSCRIPT
One factor influencing surgery for esophageal cancer is the reconstruction technique, which may involve constructing a tube from the stomach or the intestines. Good blood
RI PT
flow and adequate length are necessary (1). Gastric tube formation became easier with the availability of improved surgical staplers, but gastric tube necrosis and leakage may
SC
still occur. Therefore, a simple technique providing good blood flow to the end of the
M AN U
gastric tube is needed. One method is called whole stomach: the surgeon excises the small part of the gastric wall supplied by the left gastric artery (2,3). Another is called the gastric tube: the surgeon divides the stomach from the lesser curvature along the axis of the greater curvature. But the gastric tube method is so difficult that various
TE D
devices are used in each institution.
We use the gastric tube method, except in patients with gastric cancer or patients
EP
with a history of gastrectomy. One reason for choosing this method is that it provides
AC C
sufficient length. Length is never a problem, even in the case of the laryngo-esophagotomy. With a linear cutting-stapler, shaping the gastric tube is comparatively easy and time-saving. Since 2012, we have used the Endo-GIATM60 with Tri-StapleTM (Covidien Japan, Tokyo). To shape a long, slender tube, we usually use 6 or 7 linear staplers. The first problem is an irregular section of a knot, which causes no trouble if the serial stapling is in the same direction (Fig. 1). But once the direction
2
ACCEPTED MANUSCRIPT
shifts, inserting a linear stapler becomes difficult, and the knot becomes more notched. To shape a long tube, the angle of the first 2 staplers must be nearly a right angle. If the
RI PT
area below is the remaining side, the section is more notched. These sides are vulnerable with limited blood flow. Therefore, we developed a new technique using two types of
SC
staplers.
M AN U
Technique
We describe two methods: method A and our new procedure, method B. In both methods, the stapler was fired as often as needed to divide the stomach from the lesser curvature along the axis of the greater curvature, creating a 3- to 5-cm wide tube. The
TE D
distance between the incision and the pylorus was approximately 5 cm, where the third branch of the right gastric artery was preserved.
EP
Method A (Fig. 2): The first incision with the linear stapler was toward the
AC C
direction of the greater curvature, near the right angle of the lesser curvature. About 3 cm of the gastric wall was separated by this firing, and an area 3- to 5-cm from the greater curvature was preserved. The next staplers were set parallel to the greater curvature and fired to the cardia, so the angle of the first 2 staplers became nearly 90°. We always use six or seven staplers, 60 mm long, reinforcing the intersections with Albert and Lembert sutures, being especially careful at point b.
3
ACCEPTED MANUSCRIPT
The problems with method A are: •
Once the first stapler is set perpendicularly, it is difficult to insert the second stapler
•
RI PT
parallel to the greater curvature. The staplers overlap at the intersection.
Because of the difficulty in inserting the second stapler, we must twist the gastric
SC
wall, so the section becomes uneven. Frequently, we cannot use the stapler’s full length.
•
We must reinforce the intersections. Because of low blood flow, we always bury this
M AN U
•
intersection.
Method B (Fig. 2, dotted line): We use the GIATM Radial Reload (Covidien,
TE D
Tokyo, Japan) for the first stapler, which places three curved rows of staples 60 mm in length on each side of a cut line and simultaneously divides the tissue between the third
EP
and fourth lines (4). With this stapler, we cut the gastric wall to the estimated
AC C
gastric-tube width. Then, a linear stapler can be set tangential to the arc of the separated line. After the second stapling, we always use three or four staplers 60 mm long. To perform this method more easily and certainly, we developed a special ruler to determine 3 points. First, we mark the initial point about 5 cm from the pylorus (Fig. 3, point a). Point a was placed on a line, at the beginning of one-quarter of a circle (Fig. 4, X-Y), and the line Y-Z was parallel to and a distance of 3- to 5-cm from the greater
4
ACCEPTED MANUSCRIPT
curvature. The intersection of the end of the quarter-circle and the line Y-Z was marked (Fig. 3, point b). Point c was marked on the line Y-Z (Fig. 3), 6 cm from point b. The
RI PT
ruler was removed, and stapling was started. The GIATM Radial Reload was set on the gastric wall. The stapler tip was point b, and point a was on the stapler line. The stapler
SC
was then closed, fired, and removed. Next, the linear stapler, Endo GIA Tri-Staple 60
M AN U
was introduced from the edge of the first separation and fired. Then, we gripped the stomach with no slack and shaped the gastric tube as in method A. We do not extend the gastric wall at the time of stapling. Expansion of the gastric wall causes the transformation post-stapling. Depending on the staple size, the length of the separated
TE D
wall was often shorter than planned, mainly due to stretching caused by the stapler pressure.
EP
With method B, all of the prior problems were solved. Insertion of the second stapler became easier, and overlap of the staples decreased.
•
We do not twist the gastric wall at the time of stapler insertion, and the section
AC C
•
became linear. •
We can use the stapler’s full length. We used two linear staplers to cut from points a to c in method A, but only one with method B.
•
The intersection of the two staplers is similar to the intersection of two linear
5
ACCEPTED MANUSCRIPT
staplers with the same direction, so we omit the Lembert suture. Although the staple line length with method A is longer than with method B,
RI PT
reinforcement sutures shorten the staple line. Due to the staplers’ overlap, the staple line of method A will not become straight; additionally, the staple line (b–c) often becomes
SC
irregular because of twisting the gastric wall, and it will be shortened.
M AN U
With method B, the best direction of the second stapler is Y to Z, but we sometimes must select the direction toward the lesser curvature. Correction takes place on the third stapling or later. A correction of direction 20°, the modification of the staple line and the crush of the intersection
TE D
becomes notable. To avoid these problems, we often use the GIA Radial Reload again. Discussion
EP
Owing to the development and improvement of surgical staplers, suturing and
AC C
anastomosis of the digestive organs, such as during gastric tube reconstruction and esophagectomy, have become easier and safer. Many reports about the methods and experiments for esophageal reconstruction have been made (5). Important conditions required for reconstruction are good blood flow and sufficient length. The gastric tube’s blood supply is from the right gastric artery and gastroepiploic artery, and the blood flow of the gastric wall is decreased to the cardia. Blood flow within the stomach wall is
6
ACCEPTED MANUSCRIPT
also important. To preserve the blood flow within a wall, the whole stomach method is used. It is very easy to shape the whole stomach using one or two linear staplers.
RI PT
Linear staplers are also used to shape the gastric tube. We use the Endo GIA Tri-Stapler because of good operating characteristics and good arrest of hemorrhage. We
SC
usually use a vascular/medium cartridge with 2 mm, 2.5 mm, and 3 mm staples. With
M AN U
this cartridge, no bleeding was found at the staple line’s surface. With a narrow width, continuous stapling became easy, but the problem of the intersection remained. Rapidly turning the stapler must be avoided. Combinations of linear staplers cannot address this problem. The Radial-Reload can cut deeply with a curved line to the planned width.
TE D
Then, linear staplers can cut the gastric wall parallel to the greater curvature. In order to make a series of staplings more simply and smoothly, unification of the first and second
EP
stapler is necessary. Our specialized ruler made it possible to unify the two staplers.
AC C
After three points are decided, stapling is performed. The ruler’s slit facilitates selecting the second stapler’s direction. We have experienced an angle of ≤20° with continuous stapling. When the angle
becomes >20°, cutoff stump modification is required, and the intersection becomes large. With careful stapler insertion, we cannot discover the intersection easily. Moreover, the Radial-Reload is used not only for the first stapling but for closing the
7
ACCEPTED MANUSCRIPT
top of the gastric tube, for the esophagus and gastric anastomosis. We developed a special ruler to assist with a new method of gastric tube formation. Creating a long
RI PT
gastric tube parallel to the greater curvature, an arc about the stomach, is difficult, and it is very difficult to correct the tube’s shape before separating the stomach. With our ruler,
SC
we can make a simple and smooth gastric tube using a radial stapler together with a
M AN U
linear stapler.
REFERENCES 1.
Jean-Mare N, Abdarrahmane D, Assane N, et al. Arteriography of three models
TE D
of gastric oesophagoplasty: the whole stomach, a wide gastric tube and a narrow gastric tube. Surg Radiol Anat 2006;28:429-437.
Zhang MQ, Wu QC, Li Q, et al. Comparison of the health-related quality of life
EP
2.
AC C
in patients with narrow gastric tube and whole stomach reconstruction after oncologic esophagectomy: a prospective randomized study. Scan J Surg 2013;102:77-82. 3.
Collard JM, Tinton N, Malaise J, et al. Esophageal replacement: Gastric tube or
whole stomach? Ann Thorac Surg 1995;60:261-7. 4.
Rivadeneira DE, Verdeja JC, Sonoda T. Improvement access and visibility
during stapling of the ultra-low rectum: a comparative human cadaver study between
8
ACCEPTED MANUSCRIPT
two curved staplers. Ann Surg Innov Res 2012;13:1164-6. Kawano T, Toshino K, Endo M. Cervical esophagogastric anastomosis by the
AC C
EP
TE D
M AN U
SC
cuff technique using a stapler. J Am Coll Surg 1996;183:157-9.
RI PT
5.
9
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Schema of separation of the gastric wall with a linear stapler
RI PT
(A) Line of incision between rows of staplers. (B1-C1) The serial stapling is in the same direction
Fig. 2. The separation direction. Method A indicated by straight arrows
Fig. 3.
Surgical view.
TE D
Method B indicated by the dotted line
M AN U
↑↑↑ = staplers overlap each other at the intersection
SC
(B2-C2) The direction of the stapling has shifted
(A) The ruler and the three selected points.
EP
(B) Curved stapler was set.
AC C
(C) Curved stapler was fired.
(D) Linear stapler was fired next to the curved stapler Fig. 4. Ruler for the gastric tube.
10
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
