GASTROENTEROSTOMY

From Big Medical Encyclopedia

GASTROENTEROSTOMY (gastroenterostomia; grech, gaster a stomach + enteron a gut + stoma of companies, an opening, pass) — operation of imposing of an anastomosis between a stomach and a small bowel. It is for the first time executed in 1881 by A. Wolfler, T. Billroth's assistant. Bypassing the output department of a stomach narrowed by a cancer tumor A. Wolfler, on the advice of Nikoladoni who was present at operation (S. of Nicoladoni), connected an anastomosis the loop of a jejunum which is carried out ahead of a cross colon to a front wall of a stomach — a front vperediobodochny gastroenteroanastomosis (gastroenterostomia antecolica anterior). Soon G. began to be made not only at the stenosing cancer of antral department of a stomach, but also at a cicatricial and ulcer pyloric stenosis. In Russia G. at the cicatricial pyloric stenosis which was caused a burn of a stomach for the first time was manufactured by N. D. Monastyrsky in 1882.

Even during formation of gastric surgery numerous modifications of this operation were offered. So, Courvoisier (L. J. Соurvoisier) and finally V. Hacker in 1885 offered back pozadiobodochny G.'s method — gastroenterostomia retrocolica posterior; G. Brown — imposing of an interintestinal anastomosis between the bringing and taking away loops of a small bowel at a front vperediobodochny gastroenterostomy; To Ts. R — option G. with crossing of a jejunum with a Y-shaped interintestinal anastomosis. T. Kokher offered back G. with a cross section of an intestinal loop. Numerous G.'s modifications distinguish depending on: a) arrangements of a loop of a small bowel in relation to a stomach — from - or antiperistaltic, b) provisions of an anastomosis in relation to a longitudinal axis of a stomach — horizontal, vertical, slanting, c) lengths of the bringing loop of a gut — long, short, extremely short, d) ahead - or a pozadiobodochny arrangement of the intestinal loop anastomosed with a stomach. Most often use back pozadiobodochny G. on a short loop (isoperistaltically or vertically) and front vperediobodochny G. on a long loop with an interintestinal anastomosis.

In the first quarter of 20 century operation G. was widely applied as a method of treatment of a peptic ulcer of a stomach and duodenum. In 1906 on the Berlin congress of surgeons R. U. Kronlein defined G. as a method of the choice in surgery of a peptic ulcer. According to most of surgeons of that time G. had to provide rest to an ulcer, its mechanical shchazheniye, throwing in a stomach through an anastomosis of alkaline duodenal contents — neutralization salt to - you and by that to promote healing of an ulcer.

Despite various constructive improvements, T. at patients with a peptic ulcer yielded not very comforting results. The indisputable evidence that development is a natural consequence of use of this operation at a peptic ulcer was produced round ulcers (see).

Went. - kish. the anastomosis on condition of its normal functioning is capable to unload a stomach, to reduce time of contact of food masses with a mucous membrane; Actually does not influence gastric secretion, its regulatory mechanisms. Moreover, constant irrigation of an antrum alkaline duodenal contents promotes production of gastrin and initiation of activity of the obkladochny cells producing salt to - that.

Further researches showed that after G. also the intestinal phase of gastric secretion amplifies. Thus, the attempt by means of G. to neutralize acid gastric contents and by that to promote healing of ulcers was inefficient. In the absence of a pyloric stenosis operation does not provide also switching off of a duodenal ulcer since food masses leaves a stomach not only through an anastomosis, but also on a natural way.

Long ago the long-term discussion between G. supporters and supporters of a resection of a stomach became property of history. Resection of a stomach in surgery of a peptic ulcer, having gained the general recognition as the most reasonable and rational operation, after the 24th All-Union congress of surgeons (1938) became operation of the choice, and G. applied earlier lost any value in connection with the nezazhivleniye of the left ulcers, a recurrence of ulcers of new localization, a possibility of their malignancy which are often found after it and, the most important, in connection with the round ulcers of a jejunum or an anastomosis which are often arising after this operation.

Indications

As palliative operation G. is shown at patients with the stenosing cancer of output department of a stomach or at tumors of a piloroduodenalny zone with a prelum of a duodenum. Much less often G. is shown at cicatricial stenoses as a result of a chemical burn of a mucous membrane of output department of a stomach.

With introduction to practice of treatment of a peptic ulcer of vagisection certain surgeons revive G. as one of methods of drainage of a stomach later vagisections (see). G.'s need as independent duodenal ulcers operation demands special justification in each case. It is hl. obr, a cicatricial pyloric stenosis at the aged or sharply weakened patient, especially if gastric acidity is low.

The preparation for surgery

the Preparation for surgery consists of the elements providing carrying out any other operation on bodies went. - kish. a path (see. Stomach , operations). Anesthesia, as a rule, the general.

Special preparation is demanded by patients with a dekompensirovanny stenosis of escaping of a stomach. It consists first of all in correction of water-salt disturbances, a disproteinemia, a vitamin deficiency, includes daily gastric lavages.

Technology of operation

Fig. 1. Scheme of a gastroenterostomy: and — back (pozadiobodochny); — a lobby (vperediobodochny); 1 — a liver; 2 — a backbone; 3 — a pancreas; 4 — a stomach; 5 — a gastroenteroanastomosis; 6 — a mesentery of a cross colon; 7 — a cross colon; 8 — a big epiploon; 9 — an interintestinal anastomosis.

The most convenient access is provided by upper median laparotomy (see). At a peptic ulcer it is necessary to apply only a pozadiobodochny anastomosis (fig. 1, a) as the vperediobodochny gastroenteroanastomosis is complicated by development of a round ulcer more often. After opening of an abdominal cavity the cross colon is removed and tightened up and kpered. At a root of its mesentery in the avascular site make a vertical section up to 8 cm long. In a mesentery hem a back wall of a stomach to the formed window. At unions in an omental bursa for the best orientation previously cut a gastrolic sheaf on the small site. The stomach is anastomosed with initial department of a jejunum at once behind a duodenal and jejunal bend. At a vertical isoperistaltic gastroenteroanastomosis (G. according to Petersen) the bringing loop is located closer to small curvature, and taking away — to big curvature. At a horizontal isoperistaltic gastroenteroanastomosis (G. on Gakkera) the bringing loop is hemmed closer to the cardia, and taking away — to the gatekeeper.

At a nonresectable tumor of output department of a stomach impose a vperediobodochny gastroenteroanastomosis with an interintestinal anastomosis (fig. 1, b) as at back G. there is always a risk having handed over l e-niya an intestinal loop, anastomozirovanny with a stomach, the growing malignant tumor. The loop of a small bowel undertakes at distance of 30 — 40 cm from a duodenal and jejunal bend (G. on a long loop) and is brought to a front wall of a stomach ahead of a big epiploon and a cross colon. The anastomosis of a gut with a stomach is imposed perhaps further from a tumor.

The stomach is sewed with a gut most often two rows of seams. The first row — on a mucous membrane put a continuous catgut suture; the second — gray and serous noose silk sutures. Bringing and taking away a knee of an intestinal loop, anastomozirovanny with a stomach, in order to avoid an excess it is reasonable to hem to a wall of a stomach outside an anastomosis («suspension of a loop» on Kappelera). Between the bringing and taking away loops two rows of stitches put an interintestinal anastomosis 5 — 6 cm of Zhel wide. - kish. and interintestinal an anastomosis can be imposed by means of a stapler of NZhKA. Width of an anastomosis shall correspond to width of a gleam of the anastomosed loop of a gut. Too wide anastomosis can sometimes promote invagination of a small bowel in a stomach, and narrow it can be insufficient for effective drainage of a stomach. At a peptic ulcer also localization of an anastomosis which shall be located in the most low located part of a stomach, in its prepyloric department matters. The wrong choice during operation of an intestinal loop for went. - kish. leads an anastomosis to serious consequences. Therefore during operation special attention is paid to the choice of the anastomosed loop of a gut which can be complicated at repeated interventions on abdominal organs and extensive commissural process. Serve as a reference point for finding of a duodenal and jejunal bend an upper mesenteric artery and dvenadtsatiperstno - a jejunal fold of a peritoneum.

Postoperative maintaining patients has no features in comparison with other operations which are followed by opening of a gleam of a stomach and a small bowel (see. Stomach , operations; Intestines , operations).

Complications

At a decompensation of motor function of a stomach at patients with a pyloric stenosis in the first days after operation the gastroenteroanastomosis can not function; the patient is disturbed by feeling of weight in epigastriß area, nausea, an eructation, vomiting. In this case it is necessary to evacuate congestive gastric contents periodically. Apply also constant nazo-gastralny drainage of a stomach for 2 — 5 days. The delay of evacuation from a stomach can be also at inflammatory hypostasis of fabrics in the field of an anastomosis — an anastomositis (see. Postgastrorezektsionny syndrome ), and also as a result of the wrong topographical provision of an anastomosis.

The technical defects of operation creating an obstacle in a way of food masses to the taking-away loop of a gut (an excess of a gut, its torsion on a long axis, an antiperistaltic arrangement, etc.), can be the cause of development of a syndrome of an acute vicious circle (an acute syndrome of the bringing loop). At the same time food masses from a stomach gets not in taking away, and to the bringing loop. The bringing loop, being overflowed with the food masses, pancreatic juice and bile, stretches up to the gatekeeper through which there is regurgitation of its contents in a stomach. The stretched bringing loop, squeezing initial department of taking away, forms the «spur» which is completely closing escaping of a stomach in the taking-away loop of a gut. The vicious circle can be full (food masses makes a circulation on the bringing loop) or incomplete (there is a pendulum movement of food masses on the bringing loop). In more remote period after operation there can be hron, a vicious circle.

Klien, a picture hron, a vicious circle depending on degree of its expressiveness is various: with feeling of weight in epigastriums to the exhausting vomiting and the progressing exhaustion.

Prevention of a vicious circle consists in careful observance of all details of the technology of operation. At front gastroenteroanastomoses it is always necessary to impose an interintestinal anastomosis.

Treatment of a vicious circle operational: removal of the gastroenteroanastomosis imposed earlier (degastroenterostomiya) or imposing of an anastomosis between the bringing and taking away loops of a gut. The resection of a stomach after a degastroenterostomiya or together with an anastomosis is more radical.

Influence of a gastric juice with the kept acidity on a mucous membrane of a jejunum, anastomozirovanny with a stomach, is the main reason for development after operation of round ulcers of an anastomosis or otvodyashcheq an intestinal loop. The basic a wedge, manifestation of this complication are the pains in the field of an ulcer connected with meal.

The penetration of a round ulcer in a cross colon arising owing to anatomic proximity conducts to a heavy complication — gastrotoshchekishechnoobodochnomu (fistula gastrojejunocolica) or jejunal colonically I whistle (fistula jejunocolica). The first arises at the round ulcer of an anastomosis second at a round ulcer of the taking-away gut. Klien * a picture of these complications is caused by existence of shunting of the most part of intestines owing to what some amount of the eaten food comes from a stomach to a large intestine. Ponosa with allocation of undigested food and the sharp exhaustion of the patient which is followed by the expressed hypoproteinemia, volemichesky and water and electrolytic disturbances result. Vomiting with impurity of fecal masses is possible (see. Intestinal fistulas ).

In the remote terms after an operative measure among other complications of G. a specific place is held by a gastroenterostomichesky symptom complex, or Pribram's disease. In 1923 Pribram (V. O. of Pribram) under the name «gastroenteroanastomosis as disease» described clinic of adverse functional effects of G. connected generally with disturbance motor evakuatornoy and secretory functions of a stomach. Patients complain of feeling of weight in epigastriß area, bystry saturation, heartburn, an eructation bile, pains in the pit of the stomach and in right hypochondrium, nausea, vomiting. The conservative treatment directed to recovery of the function of a stomach broken motor evakuatornoy often does not give effect, at the patient the progressing exhaustion develops. In this case repeated reconstructive operation, character is shown the cut can be various.

At diagnosis of early and late complications have the leading value gastroscopy (see) and radiological inspection.

The lethality after G. on condition of strict observance of indications and contraindications to this operation and the correct technical performance does not exceed 1%,

the X-ray pattern after G. is rather characteristic. More often the stomach keeps the usual form and an arrangement. Depending on width of an artificial anastomosis and level of its arrangement the suspension of barium coming to a stomach already from the first drinks begins to get partially through went. - kish. an anastomosis, filling a loop of a jejunum; at considerable filling of a stomach the contrast suspension begins to be evacuated as well through the gatekeeper. There is a typical picture of a stomach with two ways of emptying — through an anastomosis and the gatekeeper.

At rentgenol, a research of a stomach after the postponed G. it is necessary to establish type of the made operation: 1) back or front gastroenteroanastomosis; 2) an anastomosis on a long or short loop; 3) existence or lack of an additional anastomosis according to Brown. At satisfactory function went. - kish. an anastomosis the first issue is resolved by a research of the patient in a side projection; at the same time it is possible to see that the hemmed loop of a jejunum which is filled with barium approaches closely to back (back G.) or a front wall of a stomach (front G.). For clarification of topographical relationship between the loop of a jejunum brought to a stomach and a cross colon investigate the provision of a loop of a small bowel, anastomozirovanny with a stomach, in relation to the cross colon contrasted by barium (in front or behind from the last). Palpation under control of the screen, attentive overseeing by advance of barium on intestines, use of the dosed compression promote determination of length of an intestinal loop, anastomozirovanny with a stomach, and existence of an interintestinal anastomosis.

Fig. 2. The roentgenogram of a stomach and intestines at a back gastroenterostomy: the anastomosis is imposed in an average third of a body of a stomach, near big curvature (1); barium a wide stream comes through an anastomosis to a jejunum (2); at the same time a part of a contrast suspension passes through the gatekeeper (3) from a stomach (4).

Task of the radiologist is also determination of level of an arrangement went. - kish. anastomosis and assessment of its function. At back G. the anastomosis most often comes to light in an average third of a body of a stomach (fig. 2). At front G. it is localized closer to the gatekeeper. Speed of gastric emptying depends on several factors and first of all on the level of an arrangement of an anastomosis and its width, and also on degree of passability of the gatekeeper.

In the first days and weeks after G. gastric emptying is in most cases slowed sharply down (to 6 — 7 hours and more).

In later terms gastric emptying fluctuates in limits: of 2 hours at portion up to 45 min. — at continuous emptying. It depends on a tone of a stomach, level of an arrangement of an anastomosis and its width. The considerable barium residue in a stomach in 3 hours after its reception demonstrates disturbance of evakuatorny function. At well functioning anastomosis the ground mass of barium comes from a stomach to the taking-away end of the hemmed intestinal loop. Receipt of a significant amount of a baric suspension in the bringing loop and its long delay in a loop which is followed by expansion of a loop, an atony, disorder of gastric emptying and a retrograde pelting in a stomach of a contrast agent confirm existence of a so-called vicious circle (nowadays rare, but still terrible complication of operation G.),

the Acute vicious circle arising in the first days after operation seldom is subject to observation of the radiologist. At suspicion on this complication it is desirable to make a research at vertical position of the patient, without resorting to a palpation. The symptoms revealed at the same time very remind a picture of high intestinal impassability. In a stomach — the wide, highly located fluid level, over the Crimea is visible the big gas bubble more often stretched in the horizontal direction. The second gas bubble decides on a horizontal fluid level (Kloyber's bowl) in a duodenum. Sometimes it is possible to find also the third accumulation of liquid and gas corresponding to the stretched bringing piece of an intestinal loop.

In certain cases, in addition to gas and liquid in a stomach, only Kloyber's bowl corresponding to the bringing loop is visible. On 5 — the 6th day after operation if the general condition of the patient allows, the research in the small portions of barium is admissible careful (without palpation).

Fig. 3. The roentgenogram of a stomach and intestines at a chronic vicious circle: a delay of barium in a stomach (1); an excess of a stomach (it is specified by an arrow) in connection with a perigastritis; insignificant receipt of contrast weight in the taking-away loop of a jejunum (3); the short bringing loop (2) and a duodenum (4) are expanded and crowded with barium; round ulcer of an anastomosis (5).

At a chronic vicious circle (fig. 3) the contrast suspension after filling of a stomach comes to the stretched bringing loop of a jejunum, liquid and gas contains edges. Barium can come to it as through went. - kish. an anastomosis, and through the gatekeeper. At the same time also all duodenum usually also sharply stretches, in a cut it is long the contrast suspension is late. Crucial importance for diagnosis of a vicious circle has overseeing by advance of a baric suspension, edges through an anastomosis gets almost only to the bringing loop; intake of barium in the taking-away loop either is insignificant, or is absent. The bringing intestinal loop is stretched also an atonichna; peristaltics here sluggish, superficial and rare. The delay of barium in the bringing loop and in a stomach can reach many hours and even days.

Rentgenol, a research plays a large role at recognition of not begun to live, recurrent and round ulcers which diagnosis is carried out by the general rules of radiodiagnosis of a peptic ulcer. Radiodiagnosis of round ulcers of a gastroenteroanastomosis and jejunum is very difficult and shall be based hl. obr. on identification of a symptom of an ulcer niche. The niche at a round ulcer can be in the form of «a niche on a contour» if at a research it is krayeobrazuyushchy, but this resistant residual contrast spot, a so-called relief niche is more often. The niche is usually surrounded more or less clearly with the expressed roller of inflammatory or vospalitelnorubtsovy character. This roller, and also more rare symptom of convergence of folds can be seen well only in aim pictures.

One of heavy complications of a round ulcer of an anastomosis is gastro and jejunal and colonic fistula, in recognition to-rogo essential value belongs rentgenol. to a research. Fistulas are formed more often after back. In the presence of fistula a baric suspension, getting from a stomach through an anastomosis into a jejunum, at the same time gets to a cross colon that is established on a picture of intestinal protrusions (haustra).

See also Stomach , Intestines .


Bibliography: Berezov E. L. Surgery of a stomach and duodenum, Gorky, 1950; Littmann I. Belly surgery, the lane with it., Budapest, 1970; Shalimov A. A.isayenkov.F. Surgery of a stomach and duodenum, Kiev, 1972; Shekhter I. A. The operated stomach in the radiological image, page 102, M., 1948; Yudin S. S. Etudes of gastric surgery, M., 1955; Dragstedt L. R. Vagotomy in the surgical treatment of peptic ulcer, Surg. Clin. N. Amer., v. 46, p. 1153, 1966; Podkaminsky, Gastroentero-anastomie mit prophylaktischer Vagotomie, Zhl. Chir., S. 568, 1925.

A. A. Greenberg; BB. H. Falcons (rents.).

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