Enteroenteric Anastomoses

Following removal of a segment of small intestine, reestablishment of the continuity of the GI tract may be performed by means of an end-to-end anastomosis, a side-to-side or an end-to-side technique. The first allows reestablishment of antegrade flow without a blind-ending pouch or interruption of the circular muscle fibers, which could result in diminished antegrade flow. The end-to-side technique allows the union of two segments of bowel with disproportionate diameters [111] (Fig. 5.41). It should be performed with the end of the proximal loop anastomosed to the side of the distal limb. This promotes drainage of the blind pouch of the distal limb. A side-to-side technique is more often utilized in cases of widespread disease or when surgery must be performed expeditiously [111] (Fig. 5.42). Any of these techniques is subject to the usual complications of dehiscence and suture line leakage. The factors affecting the integrity of the anastomosis include sepsis, tissue oxygenation, and the general nutritional and health status of the patient [111].

Figure 5.42. Side-to-side enteroenterostomy. (A, B) Spot films from a double-contrast small-bowel enema reveal a broad lumen formed by two separate loops of small bowel brought together in a side-to-side manner. (A) Small blind-ending pouch lies just superior to the anastomotic line. (B) The anasto-motic seam is well demonstrated. Films are from the same patient in whom a metastatic melanoma resection resulted in a blind-ending jejunal loop (see Fig. 5.44).

Figure 5.42. Side-to-side enteroenterostomy. (A, B) Spot films from a double-contrast small-bowel enema reveal a broad lumen formed by two separate loops of small bowel brought together in a side-to-side manner. (A) Small blind-ending pouch lies just superior to the anastomotic line. (B) The anasto-motic seam is well demonstrated. Films are from the same patient in whom a metastatic melanoma resection resulted in a blind-ending jejunal loop (see Fig. 5.44).

Blind pouches may occur following side-to-side anastomoses (Fig. 5.32) [113]. The dilatation occurs 5 to 15 years postoperatively because of the interruption of a significant length of circular muscle fibers in creating the anastomosis [111]. Usually the loop proximal to the anastomosis dilates, although occasionally both proximal and distal limbs are involved. Inadvertent side-to-end anastomoses, rather than end-to-side ones, may also result in blind pouch formation (Figs. 5.43 and 5.44).

Supine roentgenograms of the abdomen reveal a soft tissue mass or air and fluid-filled masses of varying sizes and configurations [111,113]. Contrast studies, including enteroclysis, can readily demonstrate the etiology of such unusual masses or fluid collections. Clinically a blind pouch may present with enterolith formation, diarrhea, and malabsorption secondary to bacterial overgrowth, abdominal pain, weight loss, and GI bleeding.

Figure 5.43. Blind pouch formation. Schematic drawing shows how a blind pouch forms following an improperly performed end-to-side anastomosis.

Figure 5.44. Blind-ending jejunal loop. (A) Supine film of the upper abdomen from a double-contrast enteroclysis reveals a blind-ending loop of jejunum in the left upper quadrant with the enteroclysis catheter inside it. (B) Spot film of the same area shows the blind pouch to better effect. This patient had had a previous resection of a jejunal metastasis from malignant melanoma with an end-to-side anastomosis. Preferential flow from the duodenum entered and enlarged the blind sac.

Figure 5.44. Blind-ending jejunal loop. (A) Supine film of the upper abdomen from a double-contrast enteroclysis reveals a blind-ending loop of jejunum in the left upper quadrant with the enteroclysis catheter inside it. (B) Spot film of the same area shows the blind pouch to better effect. This patient had had a previous resection of a jejunal metastasis from malignant melanoma with an end-to-side anastomosis. Preferential flow from the duodenum entered and enlarged the blind sac.

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