Enteroenterostomy

Updated: Jan 08, 2016
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Overview

Background

Enteroenterostomy is an anastomosis between one part of the small bowel and another part of the small bowel (jejunum or ileum). It is used to restore bowel continuity after resection of a segment of the bowel or after creation of a Roux-en-Y loop of jejunum. When performed as a bypass procedure, enteroenterostomy relieves bowel obstruction. [1, 2]

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Indications

An enteroenterostomy is more often performed in an emergency setting (obstruction, trauma) than in an elective setting.

Enteroenterostomy is indicated for the following:

  • After resection of small intestine (eg, for inflammatory bowel diseases such as tuberculosis, Crohn disease, malignancy [adenocarcinoma, lymphoma], ischemic stricture, trauma)
  • For intestinal bypass (short circuit) to relieve obstruction (although it is not preferred, as it may result in blind-loop syndrome)
  • As a part of a Roux-en-Y loop or Braun loop of jejunum (used for biliary-enteric, pancreatic-enteric, esophago-enteric anastomosis and as a part of gastric bypass as a bariatric procedure) [3, 4]
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Contraindications

Contraindications to enteroenterostomy include poor nutritional status (low serum albumin levels), significant hypotension during operation, irradiated bowel, poor blood supply to the bowel ends, and thick edematous obstructed or inflamed bowel ends (sutures cutting through).

In case of doubt, it is better not to anastomose but rather to exteriorize (loop stoma for a perforation and proximal stoma and distal mucus fistula after resection).

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Technical Considerations

Best Practices

Several steps can help to promote better outcomes during enteroenterostomy:

  • No tension (tension is usually not a problem in small bowel unless its mesentery is shortened, thickened, and inflamed)
  • Good blood supply of the bowel ends
  • Good (water-tight) approximation
  • No mucosal eversion between approximated bowel walls; the mucosa should be intentionally inverted
  • Serosa (visceral peritoneum) should be approximated
  • No distal obstruction

Procedure Planning

Most small bowel anastomoses are performed in the emergency setting in patients with intestinal obstruction. A nasogastric tube is inserted to decompress the stomach (and proximal dilated small bowel). Fluid and electrolyte imbalances should be corrected. Intravenous human albumin (100 mL of 20% albumin twice a day) may be used to increase the oncotic pressure and take care of the bowel wall edema. Bowel preparation is not required for small bowel resection and anastomosis (as opposed to the large bowel, in which bowel preparation is required).

Complication Prevention

An anastomotic leak is a life-threatening complication that can cause sepsis (fever, tachycardia, hypotension), abdominal signs of guarding and tenderness, multiple organ dysfunction syndrome (MODS), and even death (mortality of 10%-15%). The leak is initially small but results in a local abscess that erodes into the rest of the anastomosis or spreads into adjacent structures (including vessels) to cause bleeding. A localized leak manifests as undue or prolonged pain, unexplained fever, and unsettled abdomen with localized tenderness and paralytic ileus. A major free leak causes peritonitis; it may also present as an enterocutaneous fistula (ie, enteric contents protruding through the wound) or wound disruption (dehiscence)

Because an anastomotic leak is difficult to detect in obese and elderly patients, a high index of suspicion is necessary. In case of doubt, it can be confirmed with CT scanning with intravenous and oral (water-soluble) contrast (Gastrografin).

Anastomotic leak almost invariably requires reoperation; dismantling of anastomosis and exteriorization (proximal stoma and distal mucus fistula) should be performed. No sutures should be used in an attempt to close the leak, since they do not hold and cut through, further enlarging the leak.

Other potential complications include the following:

  • Anastomotic narrowing caused by too much inversion of walls, more so in two-layer anastomosis
  • Blind-loop syndrome in bypass and side-to-side anastomosis
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