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Gastrojejunostomy
Gastrojejunostomy Fredrick Brody, MD, and Ezra Steiger, MD astrojejunostomy was initially described by Billroth in 1881 to re-establish gastrointestinal continuity in a patient with gastric carcinoma. This is accomplished through either a gastroduodenostomy or gastrojejunostomy, depending on local anatomic factors and the surgeon's preference. Gastroduodenostomy may not be a viable option if the anatomic integrity of the d u o d e n u m is compromised. Traumatic injuries to the d u o d e n u m can compromise length and diameter, making reanastomosis impossible even after an extensive kocherization. A friable duodenal stump secondary to ulcer disease may be inadequate for an intestinal anastomosis. Furthermore, unresectable duodenal, periampullary, or pancreatic car-
G
cinoma may necessitate gastrojejunostomy, depending on the location and degree of intestinal obstruction. After any gastric resection, we prefer a tension-free gastroduodenal anastomosis (Billroth I). But problems with stump viability, tissue integrity and/or anastomotic tension may preclude a Billroth I anastomosis. On the other hand gastrojejunostomy is always a viable and safe option. Gastrojejunostomy variables include stoma size, stoma location, suture material, suture technique, and location of the jejunal anastomosis. Each of these topics is addressed in the following descriptions of hand-sewn and stapled gastrojejunostomies.
SURGICAL TECHNIQUE Hand-Sewn Anastomosis
1 The avascular plane between the omentum and greater curvature of the stomach is entered, and the posterior aspect of the stomach is clearly identified through the lesser sac. This may necessitate ligation of the most distal short gastric vessels. The transverse colon is then elevated anteriorly by the first assistant, and the middle colic vessels are identified. A three-centimeter vertical incision is made to the left of the middle colic vessels in the transverse mesocolon. -ff ~ _ ~ ' / ~ - D
From the Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Frederick Brody, MD, Department of Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 441069 Copyright 9 2000 by WB. Saunders Company 1524-153X/00/0204-0008510.00/0 doi: 10.1053/otgn.2000.19144
Operative Techniques in General Surgery, Vol 2, No 4 (December), 2000: pp 267-277
267
268
Brody and Steiger
2 The ligament of Treitz is located, and a loop of small intestine is gently introduced through the opening in the mesocolon. The afferent limb is kept as short as possible without imposing any tension along its course. An isoperistaltic or antiperistaltic position is determined after the intestine is passed through the opening in the mesocolon. Regardless of orientation, intestinal function is not altered. Therefore, loop orientation is determined by the bowel position producing the least amount of tension or torque.
3 With the bowel properly oriented, the area is packed off and the small intestine is approximated with seromuscular bites to the posterior gastric wall with two 2-0 silk sutures. The most inferior aspect of the posterior antrum is used, to ensure dependent gastric drainage.
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269
4 An interrupted posterior row of 3-0 silk sutures is placed between the two original stay sutures. These sutures are placed approximately five millimeters from each other in the seromuscular layer.
5 Electrocautery is then used to mark the gastrotomy site at least five millimeters from the posterior row of silk sutures. The gastrotomy is opened for approximately three centimeters. Any gastric contents are suctioned, and the nasogastric tube is withdrawn slightly.
270
Brody and Steiger
6 The enterotomy along the small intestine is made at the antimesenteric border for approximately 1.5 cm. The elasticity of the jejunal wall accommodates the three-cm gastrotomy without difficulty. Again, suction is used to remove any enteric contents from the jejunum. Vascular integrity, especially of the small intestine, is carefully preserved; small amounts of oozing from the enterotomy and gastrotomy are tolerated. Aggressive cautery is avoided, and bleeding edges from the enterotomy or gastrotomy are incorporated and secured with the next full-thickness suture line. Bowel clamps are not used, to avoid any iatrogenic injuries.
7 An inner suture layer is then started with a 3-0 Vicryl (Ethicon, Somerville, NJ) suture at the middle of the anastomosis. Full-thickness bites of stomach and jejunum are used for this inner layer. This stitch is run in a baseball fashion toward one corner of the anastomosis.
Gastrojejunostomy
8 A second 3-0 Vicryl suture is run in a similar fashion toward the opposite corner of the anastomosis.
9 When the full-thickness bites are no longer perpendicular across the anastomosis, a Connell stitch is done to complete the anastomosis. As the stitch exits the corner of the gastrotomy at a slight angle, it is reintroduced at the same angle into the serosal surface of the enterotomy. The stitch is now on the intraluminal surface of the jejunum. The needle is reintroduced into the jejunal mucosa after traveling three to four millimeters. The suture and needle are now through the serosal surface of the small intestine. The needle is then introduced full thickness through the gastric serosa. The suture is gently snugged so the mucosal edges of the anastomosis are inverted and the gastric and jejunal serosa are approximated.
2 71
272
Brody and Steiger
10
A Connell stitch with the other 3-0 Vicry| is started at the opposing corner.
11 As this anterior inner layer proceeds, a feeding tube may be placed across the anastomosis into the efferent limb under direct vision. The nasogastric tube is not placed across the anastomosis, because most edema resolves and intestinal function returns in 72 to 96 hours.
Gastrojejunostomy
\
12 As the two Vicryl sutures approach one another, one suture should exit the jejunal serosa while the other exits the gastric serosa. The two sutures are tied with the knot on the serosal surface, ensuring mucosal approximation and inversion, A crotchet needle may be used to help snug the entire inner layer before the final knot is tied.
13 The anterior outer layer is completed with 3-0 silk sutures placed in the seromuscular layer. Again, the sutures are placed approximately five millimeters apart. The original two stay sutures are cut, and the anastomosis is secured cephalad to the transverse mesocolon. With 3-0 silk sutures, fine bites of peritoneum along the mesocolo~a are secured to the seromuscular layer of the jejunum.
273
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Brody and Steiger
Stapled Anastomosis
14 For a stapled gastrojejunostomy, the original dissection and bowel manipulation are similar. The appropriate loop of intestine is plicated with two stay sutures, and electrocautery is used to make the gastrotomy and enterotomy sites. The operative site is isolated with laparotomy sponges. The jejunotomy site is placed on the antimesenteric border, and the gastrotomy site is positioned on the posterior and inferior aspect of the antrum. Both viscera are entered and enteric contents suctioned. Again, bowel clamps are unnecessary.
15 The two enterotomies are gently spread with a hemostat, and a GIA (gastrointestinal anastomosis) 55-millimeter stapler (US Surgical Corp, Norwalk, CT) is prepared for the anastomosis. The larger end is inserted through the gastrotomy and the smaller piece is placed through the jejunotomy. By using the two stay sutures, the stomach and small intestine are aligned. The staple line should correlate with the antimesenteric border of the small intestine and the most inferior and posterior aspect of the stomach.
Gastrojejunostomy
275
16 Allis clamps may be used at the enterotomy sites to ensure proper alignment.
17 After the GIA stapler is deployed, the anastomosis is visually inspected with the aid of a suction catheter to ensure hemostasis. Interrupted 3-0 Vicryl sutures are used as needed to ensure hemostasis. The nasogastric tube is taped into position before the anastomosis is completed. The enterostomy is closed using a two-layer hand-sewn technique, as previously described, or with a TA (thoracic anastomosis) stapler (US Surgical Corp).
276
Brody and Steiger
18 If the enterostomy is closed with a TA stapler, then the enterostomy is reoriented at an angle to avoid intersecting three staple lines. (The junction of the three staple lines theoretically functions as an "angle of sorrow" with decreased blood supply and increased risk of ischemia.) Generally, four Allis clamps are used to approximate the serosal edges of the enterostomy. The four clamps are lifted and gently spread. A 60-millimeter TA stapler is placed across the anastomosis and snugged toward the teeth of the Allis clamps. Gently wedging the TA stapler against the Allis clamps maximizes the size of the enterostomy and minimizes anastomotic impingement. The Allis clamps and the TA stapler are removed. The distal remnant previously grasped by the Allis clamps does not require excision. Although it may be aesthetically displeasing, this remnant necroses without sequelae. Amputating this remnant with a scalpel against the edge of the TA stapler results in oozing, requiring more electrocautery or interrupted sutures. The rent in the mesocolon is closed as previously described.
Discussion Many of the subtle nuances accompanying gastrojejunostomy construction are learned during surgical residency and influenced by the surgeon's preference. Whether to construct an antecolic or a retrocolic anastomosis remains a controversial issue. However, the available data addressing this topic fails to show any difference between the two techniques with regard to postoperative morbidity or mortality. In 1978, ReMine and colleagues reviewed 100 patients undergoing a gastrojejunostomy after vagotomy and antrectomy for benign duodenal ulcer disease. Of these patients, 50 underwent an antecolic gastrojejunostomy, and the other 50 underwent a retrocolic gastrojejunostomy. There were no deaths in either group. Morbidity rates were 14% for the retrocolic group and 8% for the antecolic group. This was not statistically significant. Of note, two patients in the retrocolic group required reoperation for incomplete or delayed gastric emptying, whereas one patient in the antecolic group required reoperation for delayed emptying. Although there were no statistical differences in gastric emptying between the two groups, both cohorts underwent vagectomy with gastric resection. The physiologic impact of both procedures may account for the dysfunctional gastric physiology in those three patients. Performing only a retrocolic or antecolic gastrojejunostomy without a vagotomy or gastric resection in a large group of patients may allow the effect of colonic positioning to be truly ascertained.
Gastric bypasses for unresectable pancreatic cancer are performed without gastric resections or vagotomies. Lillemoe and colleagues recently reviewed their data on prophylactic gastrojejunostomies for unresectable pancreatic cancer. All anastomoses were performed in retrocolic fashion. In theory, a retrocolic anastomosis would potentially incur a significant rate of outlet obstruction from local tumor growth. However, this group historically performs retrocolic anastomosis for resectable and unresectable disease while maintaining a low rate of postoperative gastric dysfunction or gastrointestinal obstruction despite this precarious retrocolic location. Their rate of delayed gastric emptying is 2%. Essentially, the surgeon's preference dictates anastomotic location. However, meticulous suturing with a tension-free anastomosis remains crucial, regardless of location. Similarly, patient outcomes do not differ in antiperistaltic versus isoperistaltic anastomoses. Proponents of isoperistaltic anastomosis postulate that this position is consistent with gastrointestinal physiology. However, the data fail to support this theory, and surgeon bias usually dictates this aspect of the anastomosis. Again, regardless of placement, the anastomosis must be tension free, with no unnecessary twisting or angulation. Currently, gastrojejunostomies for nonulcerogenic or oncologic procedures are performed without vagotomy. The risk of a subsequent marginal ulcer is less than 4%. Although this rate is not negligible, the use of proton pump inhibitors effectively negates this u n c o m m o n complication. On the other hand, postvagotomy syndromes,
Gastrojejunostomy including transient dysphagia (10%), diarrhea (23%), and dumping (9% to 18%), are common. These symptoms are difficult to remedy, but can be avoided by simply omitting the vagotomy while acknowledging the risk of marginal ulceration. Again, this risk is minimal and can be successfully treated nonoperatively. Even with persistent marginal ulceration intractable to medical therapy, abdominal reexploration is avoided by opting for thoracoscopic vagotomy. Postoperatively, gastric decompression is commonly performed through the nasopharynx using a nasogastric tube. Gastric decompression can also be accomplished surgically by placing a gastrostomy tube. However, most patients undergoing gastrojejunostomies are malnourished and immunocompromised. A surgically placed gastrostomy tube represents another potential source of complications, including woundinfection, abscess formation, necrotizing fasciitis, and tube dislodgement. Initially, patients are treated with nasogastric decompression to avoid such complications. If patient compliance, extended enteral feeding, or long-term decompression is required, then a gastrostomy tube can be placed percutaneously. Even in patients with prior gastric resections, percutaneous endoscopic techniques are readily available for successful gastrostomy tube placement. Finally, using either a hand-sewn or a stapled anasto-
277 mosis to restore gastric continuity results in similar morbidity and mortality rates. There are a few randomized studies as well as comprehensive reviews evaluating hand-sewn versus stapled gastroenteric anastomoses. Regardless of technique, the leak rate ranges from 1.1% to 3.0%. Furthermore, there were no significant differences between the two techniques regarding gastric emptying, postoperative anastomotic bleeding, wound infections, and intraoperative bleeding. Again, as long as viable tissue is used in a tension-free anastomosis, either surgical technique is appropriate.
RECOMMENDED READINGS 1. Becker HD, Caspary WF: Postgastrectomy and Postvagotomy Syndromes.New York,NY, Springer-Verlag,1980 2. Hoerr SO, Steiger E: Billroth II Gastrectomy,in Nyhus LM, Baker RJ (eds): Masters of Surgery. Boston, MA, Little, Brown, and Company, 1985, pp 501-514 3. Lillemoe KD, Cameron JC, Hardacre JM, et al: Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? Ann Surg 3:322-330, 1999 4. PicklemanJ, Watson w, Cunningham J, et al: The failed gastrointestinal anastomosis: An inevitable catastrophe? J Am Coil Surg 188:473-482, 1999 5. Remine SG, van Heerden JA, Magness L, et al: Antecolic or retrocolic anastomosisin Billroth II gastrojejunostomy?Arch Surg 113:735-736, 1978
G
cinoma may necessitate gastrojejunostomy, depending on the location and degree of intestinal obstruction. After any gastric resection, we prefer a tension-free gastroduodenal anastomosis (Billroth I). But problems with stump viability, tissue integrity and/or anastomotic tension may preclude a Billroth I anastomosis. On the other hand gastrojejunostomy is always a viable and safe option. Gastrojejunostomy variables include stoma size, stoma location, suture material, suture technique, and location of the jejunal anastomosis. Each of these topics is addressed in the following descriptions of hand-sewn and stapled gastrojejunostomies.
SURGICAL TECHNIQUE Hand-Sewn Anastomosis
1 The avascular plane between the omentum and greater curvature of the stomach is entered, and the posterior aspect of the stomach is clearly identified through the lesser sac. This may necessitate ligation of the most distal short gastric vessels. The transverse colon is then elevated anteriorly by the first assistant, and the middle colic vessels are identified. A three-centimeter vertical incision is made to the left of the middle colic vessels in the transverse mesocolon. -ff ~ _ ~ ' / ~ - D
From the Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Frederick Brody, MD, Department of Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 441069 Copyright 9 2000 by WB. Saunders Company 1524-153X/00/0204-0008510.00/0 doi: 10.1053/otgn.2000.19144
Operative Techniques in General Surgery, Vol 2, No 4 (December), 2000: pp 267-277
267
268
Brody and Steiger
2 The ligament of Treitz is located, and a loop of small intestine is gently introduced through the opening in the mesocolon. The afferent limb is kept as short as possible without imposing any tension along its course. An isoperistaltic or antiperistaltic position is determined after the intestine is passed through the opening in the mesocolon. Regardless of orientation, intestinal function is not altered. Therefore, loop orientation is determined by the bowel position producing the least amount of tension or torque.
3 With the bowel properly oriented, the area is packed off and the small intestine is approximated with seromuscular bites to the posterior gastric wall with two 2-0 silk sutures. The most inferior aspect of the posterior antrum is used, to ensure dependent gastric drainage.
Gastrojejunostomy
269
4 An interrupted posterior row of 3-0 silk sutures is placed between the two original stay sutures. These sutures are placed approximately five millimeters from each other in the seromuscular layer.
5 Electrocautery is then used to mark the gastrotomy site at least five millimeters from the posterior row of silk sutures. The gastrotomy is opened for approximately three centimeters. Any gastric contents are suctioned, and the nasogastric tube is withdrawn slightly.
270
Brody and Steiger
6 The enterotomy along the small intestine is made at the antimesenteric border for approximately 1.5 cm. The elasticity of the jejunal wall accommodates the three-cm gastrotomy without difficulty. Again, suction is used to remove any enteric contents from the jejunum. Vascular integrity, especially of the small intestine, is carefully preserved; small amounts of oozing from the enterotomy and gastrotomy are tolerated. Aggressive cautery is avoided, and bleeding edges from the enterotomy or gastrotomy are incorporated and secured with the next full-thickness suture line. Bowel clamps are not used, to avoid any iatrogenic injuries.
7 An inner suture layer is then started with a 3-0 Vicryl (Ethicon, Somerville, NJ) suture at the middle of the anastomosis. Full-thickness bites of stomach and jejunum are used for this inner layer. This stitch is run in a baseball fashion toward one corner of the anastomosis.
Gastrojejunostomy
8 A second 3-0 Vicryl suture is run in a similar fashion toward the opposite corner of the anastomosis.
9 When the full-thickness bites are no longer perpendicular across the anastomosis, a Connell stitch is done to complete the anastomosis. As the stitch exits the corner of the gastrotomy at a slight angle, it is reintroduced at the same angle into the serosal surface of the enterotomy. The stitch is now on the intraluminal surface of the jejunum. The needle is reintroduced into the jejunal mucosa after traveling three to four millimeters. The suture and needle are now through the serosal surface of the small intestine. The needle is then introduced full thickness through the gastric serosa. The suture is gently snugged so the mucosal edges of the anastomosis are inverted and the gastric and jejunal serosa are approximated.
2 71
272
Brody and Steiger
10
A Connell stitch with the other 3-0 Vicry| is started at the opposing corner.
11 As this anterior inner layer proceeds, a feeding tube may be placed across the anastomosis into the efferent limb under direct vision. The nasogastric tube is not placed across the anastomosis, because most edema resolves and intestinal function returns in 72 to 96 hours.
Gastrojejunostomy
\
12 As the two Vicryl sutures approach one another, one suture should exit the jejunal serosa while the other exits the gastric serosa. The two sutures are tied with the knot on the serosal surface, ensuring mucosal approximation and inversion, A crotchet needle may be used to help snug the entire inner layer before the final knot is tied.
13 The anterior outer layer is completed with 3-0 silk sutures placed in the seromuscular layer. Again, the sutures are placed approximately five millimeters apart. The original two stay sutures are cut, and the anastomosis is secured cephalad to the transverse mesocolon. With 3-0 silk sutures, fine bites of peritoneum along the mesocolo~a are secured to the seromuscular layer of the jejunum.
273
274
Brody and Steiger
Stapled Anastomosis
14 For a stapled gastrojejunostomy, the original dissection and bowel manipulation are similar. The appropriate loop of intestine is plicated with two stay sutures, and electrocautery is used to make the gastrotomy and enterotomy sites. The operative site is isolated with laparotomy sponges. The jejunotomy site is placed on the antimesenteric border, and the gastrotomy site is positioned on the posterior and inferior aspect of the antrum. Both viscera are entered and enteric contents suctioned. Again, bowel clamps are unnecessary.
15 The two enterotomies are gently spread with a hemostat, and a GIA (gastrointestinal anastomosis) 55-millimeter stapler (US Surgical Corp, Norwalk, CT) is prepared for the anastomosis. The larger end is inserted through the gastrotomy and the smaller piece is placed through the jejunotomy. By using the two stay sutures, the stomach and small intestine are aligned. The staple line should correlate with the antimesenteric border of the small intestine and the most inferior and posterior aspect of the stomach.
Gastrojejunostomy
275
16 Allis clamps may be used at the enterotomy sites to ensure proper alignment.
17 After the GIA stapler is deployed, the anastomosis is visually inspected with the aid of a suction catheter to ensure hemostasis. Interrupted 3-0 Vicryl sutures are used as needed to ensure hemostasis. The nasogastric tube is taped into position before the anastomosis is completed. The enterostomy is closed using a two-layer hand-sewn technique, as previously described, or with a TA (thoracic anastomosis) stapler (US Surgical Corp).
276
Brody and Steiger
18 If the enterostomy is closed with a TA stapler, then the enterostomy is reoriented at an angle to avoid intersecting three staple lines. (The junction of the three staple lines theoretically functions as an "angle of sorrow" with decreased blood supply and increased risk of ischemia.) Generally, four Allis clamps are used to approximate the serosal edges of the enterostomy. The four clamps are lifted and gently spread. A 60-millimeter TA stapler is placed across the anastomosis and snugged toward the teeth of the Allis clamps. Gently wedging the TA stapler against the Allis clamps maximizes the size of the enterostomy and minimizes anastomotic impingement. The Allis clamps and the TA stapler are removed. The distal remnant previously grasped by the Allis clamps does not require excision. Although it may be aesthetically displeasing, this remnant necroses without sequelae. Amputating this remnant with a scalpel against the edge of the TA stapler results in oozing, requiring more electrocautery or interrupted sutures. The rent in the mesocolon is closed as previously described.
Discussion Many of the subtle nuances accompanying gastrojejunostomy construction are learned during surgical residency and influenced by the surgeon's preference. Whether to construct an antecolic or a retrocolic anastomosis remains a controversial issue. However, the available data addressing this topic fails to show any difference between the two techniques with regard to postoperative morbidity or mortality. In 1978, ReMine and colleagues reviewed 100 patients undergoing a gastrojejunostomy after vagotomy and antrectomy for benign duodenal ulcer disease. Of these patients, 50 underwent an antecolic gastrojejunostomy, and the other 50 underwent a retrocolic gastrojejunostomy. There were no deaths in either group. Morbidity rates were 14% for the retrocolic group and 8% for the antecolic group. This was not statistically significant. Of note, two patients in the retrocolic group required reoperation for incomplete or delayed gastric emptying, whereas one patient in the antecolic group required reoperation for delayed emptying. Although there were no statistical differences in gastric emptying between the two groups, both cohorts underwent vagectomy with gastric resection. The physiologic impact of both procedures may account for the dysfunctional gastric physiology in those three patients. Performing only a retrocolic or antecolic gastrojejunostomy without a vagotomy or gastric resection in a large group of patients may allow the effect of colonic positioning to be truly ascertained.
Gastric bypasses for unresectable pancreatic cancer are performed without gastric resections or vagotomies. Lillemoe and colleagues recently reviewed their data on prophylactic gastrojejunostomies for unresectable pancreatic cancer. All anastomoses were performed in retrocolic fashion. In theory, a retrocolic anastomosis would potentially incur a significant rate of outlet obstruction from local tumor growth. However, this group historically performs retrocolic anastomosis for resectable and unresectable disease while maintaining a low rate of postoperative gastric dysfunction or gastrointestinal obstruction despite this precarious retrocolic location. Their rate of delayed gastric emptying is 2%. Essentially, the surgeon's preference dictates anastomotic location. However, meticulous suturing with a tension-free anastomosis remains crucial, regardless of location. Similarly, patient outcomes do not differ in antiperistaltic versus isoperistaltic anastomoses. Proponents of isoperistaltic anastomosis postulate that this position is consistent with gastrointestinal physiology. However, the data fail to support this theory, and surgeon bias usually dictates this aspect of the anastomosis. Again, regardless of placement, the anastomosis must be tension free, with no unnecessary twisting or angulation. Currently, gastrojejunostomies for nonulcerogenic or oncologic procedures are performed without vagotomy. The risk of a subsequent marginal ulcer is less than 4%. Although this rate is not negligible, the use of proton pump inhibitors effectively negates this u n c o m m o n complication. On the other hand, postvagotomy syndromes,
Gastrojejunostomy including transient dysphagia (10%), diarrhea (23%), and dumping (9% to 18%), are common. These symptoms are difficult to remedy, but can be avoided by simply omitting the vagotomy while acknowledging the risk of marginal ulceration. Again, this risk is minimal and can be successfully treated nonoperatively. Even with persistent marginal ulceration intractable to medical therapy, abdominal reexploration is avoided by opting for thoracoscopic vagotomy. Postoperatively, gastric decompression is commonly performed through the nasopharynx using a nasogastric tube. Gastric decompression can also be accomplished surgically by placing a gastrostomy tube. However, most patients undergoing gastrojejunostomies are malnourished and immunocompromised. A surgically placed gastrostomy tube represents another potential source of complications, including woundinfection, abscess formation, necrotizing fasciitis, and tube dislodgement. Initially, patients are treated with nasogastric decompression to avoid such complications. If patient compliance, extended enteral feeding, or long-term decompression is required, then a gastrostomy tube can be placed percutaneously. Even in patients with prior gastric resections, percutaneous endoscopic techniques are readily available for successful gastrostomy tube placement. Finally, using either a hand-sewn or a stapled anasto-
277 mosis to restore gastric continuity results in similar morbidity and mortality rates. There are a few randomized studies as well as comprehensive reviews evaluating hand-sewn versus stapled gastroenteric anastomoses. Regardless of technique, the leak rate ranges from 1.1% to 3.0%. Furthermore, there were no significant differences between the two techniques regarding gastric emptying, postoperative anastomotic bleeding, wound infections, and intraoperative bleeding. Again, as long as viable tissue is used in a tension-free anastomosis, either surgical technique is appropriate.
RECOMMENDED READINGS 1. Becker HD, Caspary WF: Postgastrectomy and Postvagotomy Syndromes.New York,NY, Springer-Verlag,1980 2. Hoerr SO, Steiger E: Billroth II Gastrectomy,in Nyhus LM, Baker RJ (eds): Masters of Surgery. Boston, MA, Little, Brown, and Company, 1985, pp 501-514 3. Lillemoe KD, Cameron JC, Hardacre JM, et al: Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? Ann Surg 3:322-330, 1999 4. PicklemanJ, Watson w, Cunningham J, et al: The failed gastrointestinal anastomosis: An inevitable catastrophe? J Am Coil Surg 188:473-482, 1999 5. Remine SG, van Heerden JA, Magness L, et al: Antecolic or retrocolic anastomosisin Billroth II gastrojejunostomy?Arch Surg 113:735-736, 1978