Enteroenterostomy
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Enteroenterostomy is an anastomosis between one part of the small bowel and another part of the small bowel (jejunum or ileum). It is used to restore bowel continuity after resection of a segment of the bowel or after creation of a Roux-en-Y loop of jejunum. When performed as a bypass procedure, enteroenterostomy relieves bowel obstruction. [1, 2]
An enteroenterostomy is more often performed in an emergency setting (eg, obstruction or trauma) than in an elective setting.
Enteroenterostomy is indicated for the following:
Contraindications for enteroenterostomy include the following:
In case of doubt, it is better not to anastomose but rather to exteriorize (loop stoma for a perforation and proximal stoma and distal mucous fistula after resection).
Several steps can help promote better outcomes during enteroenterostomy:
Most small-bowel anastomoses are performed in the emergency setting in patients with intestinal obstruction. A nasogastric tube is inserted to decompress the stomach (and proximal dilated small bowel). Fluid and electrolyte imbalances should be corrected. Intravenous (IV) human albumin (100 mL of 20% albumin twice a day) may be used to increase the oncotic pressure and take care of the bowel wall edema. Bowel preparation is not required for small-bowel resection and anastomosis (as opposed to large-bowel resection and anastomosis, in which bowel preparation is required).
An anastomotic leak is a life-threatening complication that can cause sepsis (fever, tachycardia, hypotension), abdominal signs of guarding and tenderness, multiple organ dysfunction syndrome (MODS), and even death (mortality, 10-15%). The leak is initially small but results in a local abscess that erodes into the rest of the anastomosis or spreads into adjacent structures (including vessels) to cause bleeding.
A localized leak manifests as undue or prolonged pain, unexplained fever, and unsettled abdomen with localized tenderness and paralytic ileus. A major free leak causes peritonitis; it may also present as an enterocutaneous fistula (ie, enteric contents protruding through the wound) or wound disruption (dehiscence)
Because an anastomotic leak is difficult to detect in obese and elderly patients, a high index of suspicion is necessary. In case of doubt, it can be confirmed by means of computed tomography (CT) with IV and oral (water-soluble) contrast (Gastrografin).
Anastomotic leakage almost invariably necessitates reoperation; dismantling of anastomosis and exteriorization (proximal stoma and distal mucous fistula) should be performed. No sutures should be used in an attempt to close the leak, because they do not hold and cut through, further enlarging the leak.
Other potential complications include the following:
An enteroenterostomy restores bowel continuity after resection of a segment of the bowel or after creation of a Roux-en-Y loop of jejunum. When performed as a bypass procedure, enteroenterostomy relieves bowel obstruction.
Farquharson M, Hollingshead J, Moran B, eds. Farquharson’s Textbook of Operative General Surgery. 10th ed. Boca Raton, FL: CRC Press; 2014.
Zinner MJ, Ashley SW, eds. Maingot’s Abdominal Operations. 12th ed. New York: McGraw-Hill; 2012.
Huang MQ, Li M, Mao JY, Tian BL. Braun enteroenterostomy reduces delayed gastric emptying: a systematic review and meta-analysis. Int J Surg. 2015 Nov. 23 (Pt A):75-81. [Medline].
Xu B, Meng H, Qian M, Gu H, Zhou B, Song Z. Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying. Am J Surg. 2015 Jun. 209 (6):1036-42. [Medline].
Xu B, Zhu YH, Qian MP, Shen RR, Zheng WY, Zhang YW. Braun Enteroenterostomy Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 Aug. 94 (32):e1254. [Medline].
Meng HB, Zhou B, Wu F, Xu J, Song ZS, Gong J, et al. Continuous suture of the pancreatic stump and Braun enteroenterostomy in pancreaticoduodenectomy. World J Gastroenterol. 2015 Mar 7. 21 (9):2731-8. [Medline].
Hwang HK, Lee SH, Han DH, Choi SH, Kang CM, Lee WJ. Impact of Braun anastomosis on reducing delayed gastric emptying following pancreaticoduodenectomy: a prospective, randomized controlled trial. J Hepatobiliary Pancreat Sci. 2016 Jun. 23 (6):364-72. [Medline].
Hintz GC, Alshehri A, Bell CM, Butterworth SA. Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study. J Pediatr Surg. 2018 Feb 8. [Medline].
Murata Y, Tanemura A, Kato H, Kuriyama N, Azumi Y, Kishiwada M, et al. Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy. Surg Today. 2017 Aug. 47 (8):1007-1017. [Medline]. [Full Text].
Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.
Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India
Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England
Disclosure: Nothing to disclose.
Enteroenterostomy
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