Formation of valves in gastro-enterostomy: 1, intestinal valve; 2, right-sided gastro-intestinal valve. (Bergmann.)
Fig. 555
Gastro-enterostomy with entero-anastomosis according to Braun. (Bergmann.)
Gastro-enterostomy.
—Artificial anastomotic opening between the cavity of the stomach and some part of the intestine below is indicated in a number of conditions, which have been discussed. It is done mainly, however, for two good reasons: first, to atone for pyloric stenosis, and, secondly, to give the stomach a more physiological rest in cases of gastric ulcer, permitting food to pass readily from it into the jejunum, with a minimum of gastric activity or disturbance. This particular form of anastomosis is but the application to these viscera of a general principle, which in various ways, in different parts of the body, has constituted one of the greatest features in the advance of modern surgery.
The operation is practised in two ways. In the anterior operation the highest accessible loop of small intestine is brought up in front of the omentum, or else the omentum is fenestrated in such a way that the bowel shall be brought through its window, and then attached to the anterior wall of the stomach, where the latter is much more accessible. In this operation there is less handling of the stomach and bowel, and, in general, it is easier of performance. Nevertheless the bowel loop itself may become adherent to the abdominal wound and give rise to pain, or even obstruction simulating the vicious circle. Volvulus of the jejunum has also followed it. Another objection is that as the patient gains flesh the weight of the transverse colon and omentum sometimes causes dragging upon the loop, which may cause serious trouble. The opening thus made is not where gravity will afford the best drainage of the stomach, and it is now considered undesirable in almost all cases save those where one is compelled to its performance, either by necessity for haste, or because the posterior wall of the stomach is so involved in cancerous infiltration as to afford no suitable area for fixation and opening. This method is of use mainly in dealing with malignant disease.
The posterior operation calls for all the resources of a perfected technique, and takes longer in performance. Nevertheless when once the anastomosis is safely effected it is more satisfactory.
The posterior operation alone, therefore, will be described at length in this place, and only that form of it which discards the anastomotic loop, the writer quite agreeing with the Mayos, who have had larger experience with this operation than any other surgeons, and who advise the direct attachment of the jejunum, as near as possible to the termination of the duodenum, without further complication by operative procedure. The direction of active propulsion from the stomach comes from its pyloric end, the larger end of the stomach being mainly for storage purposes and having thus a forceful action; consequently the preferable site for the stomach opening is on a line with the longitudinal part of the lesser curvature, with its lower end at the bottom of the stomach. The Mayos have abandoned reversing the jejunum and now apply it directly to the posterior wall of the stomach from right to left exactly as it lies under normal conditions, having had better results with this method than with any other.