The original publication is available at http://www.samj.org.zaTechniques of oesophagojejunal anastomosis were studied
in chacma baboons (Papio ursinus ursinus). End-to-end
anastomosis utilizing a Roux-en-Y loop and interrupted
silk sutures gave the best results. End-to-side anastomosis
performed in 3 animals resulted in jejunal volvulus.Publishers' versio

Van Rensburg, L. C. J.

Stellenbosch University SUNScholar Repository

4 ugu t 1979 MEDICAL Jo R AL 173Oesophagojejunal nastomosis after Total GastrectomyL. C. J. RE B RGSUMMARY TECHNlQTechniques of oesophagojejunal anastomosis were studiedin chacma baboons (Papio ursinus ursinus). End-to-endanastomosis utilizing a Roux-en-Y loop and interruptedsilk sutures gave the best results. End-to-side anasto-mosis performed in 3 animals resulted in jejunal vol-vulus .Before the tomach i removed. a oft clamp. u ually aa cular clamp. is applied to the oe ophagus 10 pre ent re-(raction of the muco a (Fig. I). n adequate length ofesophagus can alway be found. High tran ection of thevagi IOcrea es thi~ length (Fig. 2) Roux-en·Y loop I--------Fig l. Vascular clamp on oesopbagus.MATERIAL AND METHODS. A/I'. med. J.. 56. 173 (1979).The immediate postoperative mortality rate after totalga trectomy varie from 5 ob to 35°" ,'., The most commoncause of death is leakage at the oe ophago-enterostomyanastomosis. This particular problem wa studied experi-mentally in chacma baboons (Papio IIrsinlls IIrsinus). Itmust be emphasized that our purpose was to develop amethod for this anastomosis, and a food re ervoir watherefore not con tructed. The nutritional aspects. althoughmteresting. will not be discussed in thi paper.The u ual indication for total ga trectomy is carcinomaof the stomach. Although the incidence of this condition idecreasing in certain countrie . e.g. ew Zealand. Australia.the A and the K. it is till prevalent in countrie sucha Ru sia. Japan. Chile. Poland and candinavia. and hasa high incidence in this country among the Coloured popu-lation of the We tern Cape.tomach cancer i often diagno ed late and the overallre ectability rate i between 500~ and 60 0n. Radical urgerywith the aim of eradicating the di ea e i pos ible in onlyI in 4 patient .' It is generally believed that about 20 - 40°0of patients with carcinoma of the tomach will require totalga trectomy.'·3.'.•Department of Surgery, Tygerberg Hospital and niversity ofStellenbosch, Parowvallei, CPL. C. J. VAN RE:\' BURG. ~DIED. (SURG.,. F.C.S. (S.A.. F.R.C.(Pre nt address: :2 ~Iedipark. Fore. hor. Cape Townf) ••• recei\ed IQ September 1978 Fig. 2. Oesophagu dhided.Chacma baboons weighing between 12 and 15 kg were u edin this tudy. Total gastrectomy. with splenectomy, was per-formed. The duodenum wa closed in two layers. Thetechnique for the oesophago-enterostomy anastomosis wasstandardized but the suture material varied. All the opera-tion were performed under general anaesthesia and theabdominal route was used exclu ively.In the fir t 3 baboons an end-to- ide oesophagojejunalanastomo i with an entero-enterostomy was done. but allthe animals died from volvulus of the jejunal loop. Themall-bowel mesentery is very lax in the baboon. andsplinting the anastomosis with a na ogastric tube is notalways pos ible. Thi . combined with indi criminate feed-ing. probably caused volvulus in these case. We there-fore re oned 10 an end-to-end oe ophagojejunal ana 10-010 i u ing a Roux-en-Y loop.174 A MEDIE E TYD KRIF 4 Augustll 1979Fig. 3. Pr·eparing Roux-en-Y loop.then fashioned (Fig. 3). the proximal end of the jejunumbeing ecured with a small va cular clamp. The first rowof lItures i inserted imo the oe ophagu~, ·tarting po ·ter-iorly. Six - eight interrupted sutures are inserted fromwithout to within the lumen. It is importam to en ure thatFig. 5. Anterior ftexion of oesophagus to facilitate oeso-phagojejunal anastomosis.an adequate cuff of muco~a i included in (he suture (Fig.4). These suture ends are then held in mo quito forcepand the oesophagus i pulled upward and forward. ex-posing its posterior a pect (Fig. 5). This manoeuvre makeit easy to insert and tie an outer interrupted seromuscularlayer of sutures (Fig. 6). Once again 6 - 8 sutures are lIsed.The end of the jejunum is trimmed, and it is very easy toloop the oesophageal uture over the mucosal end andthrough the jejunum from within outwards (Fig. 7). Thesutures are tied, giving an adequate and accurate mucosa-to-mucosa uture line (Fig. 8). The knots are snugly buriedin the crevice between the two segments of bowel. Theanterior layer is then completed in a similar fashion (Fig'9 and 10). Finally, the ana ·tomosis is anchored to thediaphragm by 2 sutures. An end-ta-side entero-ana ·tomosi~i then completed in two layers. about 20 - 25 cm distalto the proximal anastomosi . (Fig. 11.)As there were no problems of volvulus with this type ofanastomosis, no attempt was made to splint the anastomosiswith a tube.II\\~\\\\\~ \ :~j ;{C-/.i1/" ,'~ I~~Fig. ~. In5ertion of all-layer suture. Fig. 6. Posterior oesophagojejunal anastomosis complete.4 I ugu t 1971J A MEDICAL JOUR 'Al 175Fig. 10. Completion of anterior layer.Fig. 9. Anterior full-thickness sutures in place.3rd and 60th postoperative day.End-to-end oesophagojejunal anastomosis with Roux-en-Y loop proximal anastomosis of the inner and outerlayers with interrupted 3 - 0 black ilk caused malnutritionand death in 1 animal on the 200th postoperative day.One animal had jejunojejunal intussusception and died onthe nnd postoperative day, and I died on the 32nd post-operative day from left ba al pneumonia. All ana tomo e~were patent.End-to-end oesophagojejunal anastomo i with Roux-en-Y loop proximal anastomosis of the inner layer wa donewith interrupted 3 - 0 chromic catgut and of the outer layerwith interrupted 3 - 0 black silk in 3 animal. All 3 died ofmalnutrition on the 150th, 162nd and 147th postoperativedays. All anastomoses were patent.--"Fig. 7. All posterior inner layer full-thickness sutures inplace.Fig. 8. All inner layer sutures tied, showing mucosa-to-mucosa anastomosis.~hd-to-side oesophagojejunal anastomosis with jejuno-Jejunostomy caused volvulus of the jejunal loop and deathIn the first 3 animals on the 26th. 15th and Ist postoperatived~y .End-to-end oesophagojejunal anastomosis with aR'oux-en-Y loop proximaJ anastomosis using interrupted4. 0 polyglactin (Vicryl) on both layers caused stenosis ofthe oesophago-enterostomy and death in 2 animals on theRESULTS176 SA MEDIESE TVDSKRIF 4 Augustus 1979being 32 days and the longest 200 days. The cause of deathwas malnutrition in 4, left basal pneumonia in 1, andjejunojejunal intussusception in I. At postmortem examina-tion no evidence was found of alkaline oesophagitis, whichconfirmed the importance of siting the distal end-to-sidejejunal anastomosis at least 25 cm below the proximalanastomosis.' There was no evidence of stenosis at theoesophagojejunal anastomosis. End-to-side oesophagoje-junal anastomosis resulted in volvulus of the jejunal loopin the 3 animals in which it was used. It was found thatan end-to-end anastomosis was more successful; thereforethe end-to-side technique was discontinued.The principles and techniques of this type of anastomosishave been adequately described in the literature:-w and wewould like to emphasize two important aspects, i.e. a ten-sion·free suture line and an accurate mucosal approxima-tion. This is easily obtained using this technique, whichhas been used in several patients with no problems.The application of a clamp to the oesophagus could becriticized, especially after extensive mobilization of theoesophagogastric junction in a patient with gastric carcino-ma. However, the function of the clamp is merely to holdthe oesophagus lightly to prevent mucosal retraction. Itdoes not crush the tissue thereby interfering with its bloodsupply.I wish to thank the Harry Crossley Research Fund forfinancial assistance, and my able assistants, Messrs G. Louw,L. Nieuwenhuizen, J. Meyer and J. J. Geldenhuys of theSurgical Research Unit of Tygerberg Hospital. I am also, indebted to Dr B. McCulley for the postmortem reports., "~'':''';';''';';''.;.;l\_'._....'~Fig. 11. End-to-side .entero-anastomosis completed in twolayers.DISCUSSION REFERENCESThe best results were obtained with an end-to-end oeso-phagojejunal anastomosis when interrupted 3 - 0 black silkwas used for both layers, and when an outer layer ofinterrupted black silk with an inner layer of 3 - 0 chromiccatgut was used. 0 leakage from the proximal anastomosisoccurred in the 6 animals in which these suture materialswere used. All 6 animals died, the shortest period of survivalI. Lundh, G., (an Burn, J., Kolig. G. er al. (1974): Ann. roy. Coli. Surg.Engl., 54, 219.2. ReMine. W. H. and Priestly. J. T. (1966): Ann. Surg., 163, 736.3. Inberg. M. V.. Heinonen. H .. Rantakokko, V. e, al. (1975): Arcb.Surg., 110, 703.4. Paulino, F. and Roselli, A. (1973): Curr. Prob. Surg .. December, p. 3.5. Marsball, S. F. (1956): Surg. Clin. N. Arner., 36, 673.6. Lawrence, W. and Mc eer, G. (1960): Surg. Gynec. Obstet.. 111,691.7. Zanaroni, A. (1977): Minerva med. 68, 311.8. Paulino, F. (1970): Hospital (Rio de J .), 77, 27.9. Marshall, S. F. (1956): Surg. Clin. N. Arner., 36, 673.10. Horisbi, A. (1973): Arcll. Surg., 107, 513.Books Received Boeke OntvangCurrent Medical Diagnosis and Treatment 1979. By M. A.Krupp, M. J. Chatton et al. Pp. 1130. Illustrated. $18,00.Los Altos, California: Lange Medical Publications. 1979.Psigologiewoordeboek. Deur L. A. Gouws, D. A. Louw,W. F. Meyer en C. Plug. Pp. 484. RI0,95. Johannesburg:McGraw-Hill Boekmaatskappy. 1979.Obstetrics (Fundamentals of Obstetrics and Gynaecology,Vol. 1). 2nd ed. By D. Llewellyn-Jones. Pp. 471. DIus-trated. £12,00. London: Faber & Faber Limited. 1977.Conduct Disorders in- Youth. By L. Schlebusch. Pp. viii +118. Illustrated. R7,75. Durban: Butterworth & Co. (SA)(Pty) Ltd. 1979.Gynaecology (Fundamentals of Obstetrics and Gynaecology,Vol. 2). 2nd ed. By D. Llewellyn-Jones. Pp. 296. Illus-trated. £11,50. London: Faber & Faber Limited. 1978.Echocardiography: A Manual for Technicians. By ChristineMiskovits and E. Frederici. Pp. 224. Illustrated. Berne:Hans Huber Publishers. 1977.

Oesophagojejunal anastomosis after total gastrectomy

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Oesophagojejunal anastomosis after total gastrectomy

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