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.

In brief the operation is as follows: Incision is made a little to the right of the median line, the transverse colon is withdrawn by steady traction to the right and upward, and the mesocolon made to follow it until the jejunum comes into view. The latter is then grasped at a distance of three or four inches from its origin. When, now, it is drawn tight the fold of peritoneum which covers the so-called ligament of Treitz is demonstrated; this is a small band containing muscle fibers, having its origin on the transverse mesocolon and extending down to the beginning of the jejunum, thus acting as a suspensory ligament. It leads to the base of the vascular arch of the middle colic artery, and indicates the place where the mesocolon should be torn through in order to expose the posterior wall of the stomach. At this point, in the least vascular area which can be discovered, the mesocolon is first incised and then torn, until a good liberal opening is made, through which the posterior wall of the stomach is easily exposed, and, later, drained. It should be forced through this opening by combined manipulation with one hand introduced above it and gently urging it through the opening where it presents. It may be easily identified by its resemblance to its anterior surface in its thickness, the arrangement of its vessel and the like. The posterior wall alone is then secured and drawn through the mesocolic window, in such a way that after the jejunum is attached to it the anastomotic opening can be made at a point one inch above the greater curvature and ending at the bottom of the stomach two and a half inches to the left of the pylorus. This area having been exposed and prepared, a considerable portion of it is drawn into a pair of specially constructed clamps (Doyen’s or Moynihan’s), whose blades are usually protected with rubber. The Mayos prefer to have the handles lying to the right and to direct the forceps transversely to the body axis. Moynihan prefers to reverse this direction and make them point to the right shoulder. The stomach being thus protected, and prevented from slipping by suitable tightening of the clamps, the jejunum is similarly secured with forceps lying in a direction parallel to the first, having within their grasp a portion of the gut extending between points one and a half and three and a half inches from its origin. If this be properly effected the left low point of the stomach lies in the grasp of one pair of clamps and the first part of the jejunum in that of the other, and these two portions should be easily brought into close contact with each other. A gauze pad having been placed behind the damps in order to avoid soiling, should there be any leakage of intestinal contents, the clamps should now be carefully and attentively held by an assistant, and their distal ends may even be bound together in such a way that, after the suturing process has once begun, nothing shall disturb the perfect contact between the surfaces thus mutually applied. The first row of sutures, usually of the ordinary continuous type, is made of silk or thread, the serous and muscular coats being seized and united over a line some two inches in length, the suture being carefully secured at either end of this line. Next, with a scalpel, an incision is made through the serous and muscular coats, parallel to the line of sutures, at a distance of about one-quarter of an inch, and over a length a trifle less than that of the line which they occupy. Here the vessels will bleed freely and forceps may be momentarily used for their securement. Through the opening thus made the mucous membrane will prolapse. Moynihan especially has shown that it is not enough to merely incise this membrane in the same direction as the other coats, but that a narrow elliptical portion of it should be excised, since it tends to prolapse. Therefore with knife or scissors a strip of the mucosa, perhaps a half-inch in width, should be cut away from either surface, thus widely opening into and exposing the interior respectively of the stomach and of the gut. Extreme pains should now be given to prevent both leakage and soiling, and instruments used upon the mucosa should be discarded after it has been divided and sutured. Now with reliable chromicized catgut a row of continuous sutures is applied by which all three coats of both cavities are bound snugly together, the needle passing through six distinct layers as each stitch is made. These sutures should be drawn sufficiently and secured at frequent intervals so as not only to ensure perfect application but sufficient pressure to prevent hemorrhage when the clamps are released. The lower side having been first closed the same character of sutures is continued until the upper margin of the buttonhole-like opening is thus completely closed. The fourth line of sutures, this time of the same material as those used in the first, is applied in a similar fashion, and with it the serous and muscular coats are accurately affixed to each other in such a way that there can be no leakage. Two or three extra sutures at either end of the line may be inserted for greater security. The clamps are now withdrawn, the gauze behind the anastomotic opening is removed, and it should be found that the smaller bowel is neatly and perfectly fastened to the posterior stomach wall and that no possibility either of hemorrhage or of leakage remains. This being accomplished there remains only to tack the margins of the mesenteric opening to the posterior wall of the stomach, at a distance sufficient to prevent all possibility of subsequent constriction or strangulation, after which the parts are carefully cleansed, restored to the abdomen, the colon and omentum dropped back and made to cover them, and the abdominal wound closed as usual. (See Figs. 556, 557 and 558.)

Such is the operation with suture, which may occupy from thirty to forty minutes in performance, it takes a little longer than the methods either with the button or with the elastic ligature, but seems to be the method generally used. In this method, as stated at the outset, no special provision is made as against “vicious circle,” because it has been found that it is seldom that this unpleasant complication ensues. If, however, the anastomosis with the jejunum has been made at a point twelve inches or more beyond its beginning, there is a likelihood of finding that vicious circle will cause later complications, and perhaps necessitate the performance of a second anastomotic opening in the small intestine above and below the stomach opening.

Of course all the precautions mentioned previously for prevention of infection, such as washing out the stomach previous to the operation, and ensuring both its emptiness and that of the upper bowel, are a part of these procedures and cannot be safely neglected in any of them.

Many an ingenious device for effecting the same kind of communication between the stomach and the bowel, or between various parts of the alimentary canal, has been placed before the profession, though but a few will be considered more in detail when dealing with the operations upon the intestines proper. The most prominent of them, and the one which has found the most lasting favor in the eyes of the profession, is the Murphy button, or some similar expedient, by the use of which time is economized and the operations in some respects simplified. All devices of this character, however, depend upon a necrotic process for their eventual success, as the intent is that parts compressed between the halves of the button shall first adhere and then slough, the button falling through the opening thus made and passing on. But to rely upon a necrotic process is much like relying upon a criminal for the performance of a serious duty. The button, therefore, has gone out of general favor for purposes of gastro-enterostomy, although for other intestinal work it is still frequently used.

McGraw, of Detroit, has devised a different and equally ingenious method of keeping surfaces in contact with each other until adhesion shall have occurred, and then effecting a further necrotic process by which opening shall be finally accomplished. This is the so-called method with the elastic ligature. In many respects it is simplicity itself, and permits of ready and rapid employment. One needs especially a round rubber cord, about 2 Mm. in diameter, of the purest gum obtainable and sufficiently fresh to be reliable. The surfaces to be united are first approximated by a posterior row of silk or thread sutures which shall include their outer surfaces. Then a long straight needle armed with this rubber cord is passed into the intestine and out again at a distance of from 5 to 10 Cm. An assistant now holding the intestine, the operator stretches the rubber suture until it is very thin and then draws it rapidly through the bowel. This same step is repeated in the opposite direction within the stomach. A strong silk ligature is next passed across and underneath the rubber between the latter and the point where the stomach and the intestine are to come together and a single knot is then made in the rubber after it has been tightly drawn. Another silk ligature is passed around beyond the ends of the rubber ligature where they cross and is here securely tied. The rubber ends thus released are then cut off. The original silk suture is next continued around in front until the point of its beginning is reached. In this way the rubber ligature and the parts which it includes are surrounded with an elongated ring of silk sutures, and with this the operation is complete. Here it is the continuous pressure of the elastic suture which first shuts off the circulation and finally cuts its way through both coats, and permits the communication between the bowel and the stomach. This method is as applicable to other portions of the alimentary canal as to the stomach.