Anastomoses in the Alimentary Tract Using aSero-Muscular Tubular Cuff Technic

W. W. LINDENMUTH, M.D., CARL J. MAY, M.D.

From the Department of Surgery, Yale University School of Medicine, New Haven,Connecticut, and the Veterans Administration Hospital, West Haven,

Connecticut

THE TECHNICAL PRINCIPLES of intestinalanastomoses seem so well founded thatthere is reluctance to consider new con-cepts. The high incidence of and the highmortality from leakage at the site of esoph-agogastric anastomosis is well known.8Our experience with esophagojejunal anas-tomoses stimulated a review of the basicanatomy and a re-evaluation of principleswhich have been accepted for many years.Lembert 12 in 1826 first emphasized the

importance of serosa to serosa appositionto assure early healing.. The clinical suc-cesses of Billroth 3in 1877 strengthened thisconcept. Senn 15 in 1888 reported extensiveexperiments aimed at a rapid method ofanastomosis. He devised a bone platewhich could be inserted through an inci-sion in the bowel wall and fixed to theinner wall with sutures which were tied toa similar plate in the opposite loop of intes-tine. The plate was gradually digestedwhile healing occurred. Senn finally recom-mended decalcified bone plates (Fig. 1).Other investigators using the same princi-ple recommended other digestible mate-rials: Baracz 2 used pieces of turnip, Lan-derer 11 potato tubes and Alessandri 1 tubesof macaroni dough. The Murphy button 13was the final effort of this type which hadconsiderable usage.

Submitted for publication November 21, 1966.Presented in part before the New England Sur-

gical Society, September 30-October 1, 1966,Portsmouth, N. H.

In 1880 Czerny7 suggested the need forstronger and more accurate mucosal appo-sition. His technic used two rows of su-tures, an inner continuous silk suturethrough all layers and an outer row, asrecommended by Lembert,12 to seal againstleakage of through-and-through sutures.Kocher 10 described a similar two-layeredtechnic in 1903. He stressed the mainte-nance of adequate vascular channels par-ticularly in end-to-end anastomoses.

Halstead and Mall 9 contributed experi-mental evidence of the importance of thesubmucosa in intestinal anastomosis. Theyadvised catching the tough submucosawith each intestinal stitch, thereby givingstrength to the anastomosis. Connell 5, 6noted that the submucosa, while verytough, is thin and to be sure of includingit, it is necessary to penetrate it and mu-cous membrane as well. Accurate approxi-mation of the various layers with fine in-terrupted sutures, as recommended bySweet 16 in esophagogastric anastomoses, isthe ultimate desire of all surgeons but fre-quently is difficult to accomplish.In our experience anastomosis of esoph-

agus to jejunum continues to be a challeng-ing problem. Ligation of vessels at the endof a mobilized jejunal loop in preparationfor inversion and serosal apposition jeop-ardizes blood supply. Furthermore, accu-rate approximation of redundant and pout-ing jejunal mucosa with the esophagealmucosa is seldom satisfactory. Necrosis or

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ANASTOMOSES IN THE ALIMENTARY TRACT

Plate withintheIntestine abovea"at of obstrUo-tion.

"

FIG. 1. Senn's boneplate.

leakage occur frequently. To correct thesedeficiencies in esophagojejunal anastomosisa technic of excision of jejunal mucosa for1 or 2 cm. and suturing the resulting sero-

muscular cuff around the esophagus with-out inversion was developed. This methodpreserves vascular channels to the endof the jejunum. Also mucosa-submucosallayers could be firmly sutured withoutpenetrating the serosa of the jejunum.Healing of the apposed muscular layerswas investigated and is the subject of thispaper.

Experiments

Experiments were performed on 12 dogs.A Roux-en-Y loop of jejunum was preparedby excising the mucosa of the proximalsegment for a distance of 1.5 to 2 cm.

(Fig. 2). This loop was brought into thechest through an incision in the diaphragmand anastomosed to proximal transectedesophagus, the distal esophagus havingbeen closed. Four traction sutures of 000chromic catgut were placed equidistantaround the circumference to guide approxi-mation of the esophagus to the edge of themucosa-submucosa within the jejunal tube.The full thickness of the esophagus was

sutured to the jejunal mucosa and sub-mucosa (Fig. 3). Each of the four guidesutures then approximated a quadrant of

Perforated de-o-lflned bone

the circumference of the esophagus to jeju-nal mucosa-submucosa. Usually the musclelayer of the jejunum was included in thesutures but serosa was avoided. The sero-

muscular flap of jejunum was then suturedto the external wall of the esophagus withinterrupted silk sutures. WVith this technicno vasa recti were ligated at the end ofthe jejunum (Fig. 4).

All experimental animals did not do well.Four developed mesenteric thrombosissoon after operation and died. One died

SERO-MUSCULAR CUFF ANASTOMOSIS

Preparation of Cuff -

FIG. 2. Surgical technic.

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LINDENMUTH AND MAY Annals of SurgeryApril 1967

Details of AnastomosisFIG. 3. Surgical technic.

on the fifth postoperative day because ofgangrene of the jejunal loop but the sero-

muscular cuff was viable and firmly at-tached to the esophagus (Fig. 5). Theanastomosis leaked in one animal in whichthere was early gangrene. Four animalswhich survived for 2 to 4 months had no

anastomotic strictures.Microscopically (Fig. 6) there was good

healing between the esophageal and jejunal

FIG. 4. Completed esophagojejunal anastomosisin a dog.

FIG. 5. Cuff attached to the esophagus despitevascular thrombosis of the jejunum (5 days) fol-lowing surgery; external surface with the esopha-gus to the left.

muscle layers with minimal scarring. Itwas concluded that, at least in the dog,this technic was easier than the acceptedmethod. Leakage and stenosis were not ap-

parent after a short period of observation.These studies supported the conclusionthat healing between muscle layers andmucosal-submucosal layers is adequate andprevented leakage.

Clinical Application

Vascular anatomy of the jejunum in thehuman was reviewed. Cokkinis' 4 andNoer's 14 studies showed that the vasa rectiin the jejunum do not anastomose withadjacent vessels except in the wall (Fig.7). These anastomoses are most numerous

in the antimesenteric portion and wouldbe best preserved by using the seromuscu-

lar cuff technic for anastomosis.Clinical trial was undertaken in patients

with carcinoma of the esophagus. Esopha-geal replacement by retrosternal jejunalloops and cervical esophagojejunal anasto-moses were undertaken in seven instances.The cervical esophagus was anastomosedto the jejunum by the technic described.Although vascular thrombosis of the retro-sternally transplanted jejunum occurred infour instances the anastomosis was intact

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ANASTOMOSES IN THE ALIMENTARY TRACT 593

FIG. 6. Photomicrograph (low power) saggital section of esophagojejunal anastomosis in dogat 4 months.

in all. X-rays of a barium swallow in twopatients at 3 and 4 weeks after operationare shown in Figures 8 and 9. Three pa-tients survived for 3 to 12 months and atautopsy there was satisfactory healing withno strictures. The autopsy specimen of one

patient who lived for a year is shown inFigure 10.Use of jejunum as a replacement for the

esophagus has been abandoned in our

clinic because of the high incidence ofvascular thrombosis but the anastomoticmethod described has been applied in threepatients in whom the right colon was usedwith survival in all.

After this experience the method was

applied in other lesions in which a Roux-en-Y jejunal loop was used as a conduit.In two patients with injury to the biliarytract the loop of jejunum was anastomosedto biliary ducts in the scarred porta hepatis.In each instance the resultant lumen was

approximately 1.0 cm. in diameter. In twopatients with obstruction at the junctionof the right and left biliary ducts, one

caused by tumor and one by surgicaltrauma, this method was used to cover a

large section of liver which had been in-

Fig. 2

JI.3

FIG. 7. Drawing by Cokkinis4 emphasizing thelack of anastomoses between vasa recti. (Drawingreprinted by permission of the author and Cam-bridge University Press, American Branch, NewYork.)

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594 LINDENMUTH

FIG. 8. Esophagogram showing an esophago-ileostomy 3 weeks after surgery demonstrating anadequate stoma at the site of anastomosis.

*~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ...... ._

FIG. 9. Esophagogram showing an esophago-jejunostomy a month after surgery illustrating freepassage through a wide anastomotic channel.

AND MAY Annals of SurgeryApril 1967

cised in search of patent intrahepatic bili-ary channels.The method was satisfactorily applied in

anastomosis of jejunum with cut surfaceof the pancreas and in one patient in whomduodenal resection for ulcer was carriedinadvertently beyond the ampulla of Vater.In the latter case exposed openings of thecommon bile duct and pancreatic ductwere anastomosed to a Roux-en-Y loop ofjejunum.

Implantation and anastomosis of esopha-gus to distal gastric remnant after resec-tion of the esophagogastric junction hasbeen accomplished by this technic. Exci-sion of mucosa 1 to 2 cm. beyond the lim-its of the button removed from the gastricwall prepares a seromuscular cuff whichis sutured around the esophagus after thefull thickness of the esophageal wall hasbeen sutured to the edge of the mucosa-submucosa within the denuded gastricwall. Figure 11 shows x-rays of a patientwith a large invasive carcinoma of thelower esophagus and upper stomach whowas relieved for 10 months.A modification of the method was used

in a difficult duodenal closure after gastrec-tomy for postbulbar ulcer with obstruc-tion. Proximal duodenum and pylorus

FIG. 10. Mucosal surface of the esophagojejunalanastomosis (a year after surgery) opened longi-tudinally. The arrows indicate the sites of the su-ture lines.

ANASTOMOSES IN THIE ALIMENTARY TRACT

TABLE 1. Various Types of Procedures Using thleSeromuscular Tubular Cuff Technic

for A nastomosis

Total Experience of 27 Cases

Esophago-enterostomy 10Pancreatic-Cystojejunostomy 3

Choledochojejunostomy (Extra) 5Esophagogastrostomy 1Ampullary Jejunostomy 1Duodenal Stump Closure 7

were dilated to a diameter of 5 to 6 cm.

The duodenum was transected distal to

the pylorus preserving its blood supplyand duodenal mucosa was excised proxi-mal to the point of obstruction. The edgeof mucosa-submucosa at the base was su-

tured with continuous catgut. The muscu-

laris was apposed with a similar suture andthe end of the cuff was closed with silksutures without inversion. The method was

used for duodenal closure in seven in-stances in which mobilization of a distortedduodenum would have been difficult. Allpatients have done well with no leakage.Table 1 summarizes clinical experiences

with this anastomosis. The esophago-entericanastomoses include seven esophagojeju-nostomies, two esophago-ileostomies, andone esophagocolostomy.The following case summaries include

all patients who had complications relatedto the operation.

Case 1. J. T., a 37-year-old man with pepticulcer complicated by bleeding, obstruction andweight loss was operated upon and during gas-

trectomy the ampulla of Vater and a separate pan-

creatic duct were inadvertently isolated proximalto the duodenal closure because of a scarred andcontracted duodenum. These openings were anas-

tomosed to a Roux-en-Y jejunal loop from the end

of which 1.5 cm. of mucosa had been removed

and a two-layered silk anastomosis to the scarred

pancreatic capsule was carried out. Postopera-tively the patient had no peritoneal irritation or

drainage and his course was uncomplicated. The

patient has since been unable to gain weight buthe is working regularly 21/2 years after operation.

Case 2. W. R., a 43-year-old man with re-

curring pancreatitis and a pancreatic pseudocystunderwent a cystojejunostomy by anastomosingRoux-en-Y the jejunum (from the end of which1 cm. of mucosa was stripped) to the cyst wall.His postoperative course was uncomplicated.

Case 3. S. T., this 46-year-old man had sus-

tained a common duct injury during cholecystec-tomy for acute cholecystitis 3 months previously.At operation an opening 1.0 to 1.5 cm. was estab-lished in the scar at the junction of the right andleft main hepatic ducts. No definite segment ofcommon duct could be fashioned. The seromuscu-

lar cuff on a Roux-en-Y loop of proximal jejunumwas used for mucosal apposition of the cuff toadjacent scar. The postoperative course was un-

complicated but the patient returned 2 years later

FIG. 11. Esophagogram showing the esophago-gastrostomy 16 days following surgery indicatingexcellent patency without fistula or stricture.

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596 LINDENMUTH AND MAY Annals of Surgery596 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Ap)ril 1967

with cholangitis. Upper gastrointestinal x-raysshowed that intestinal contents entered the biliarytract. At reoperation the jejunal loop was length-ened to 60 cm. The anastomotic ring admittedonly a 5 mm. dilator; this was dilated to 10 mm.Since this procedure he has done well except forone mild attack of cholangitis.

Case 4. C. A., a 30-year-old man developedchemical esophagitis with mediastinal abscess, bi-lateral pneumonia, pericarditis and esophago-bronchial fistula after ingestion of Draino in Au-gust, 1965. Cervical esophagostomy and feedingjejunostomy were performed. He improved but re-quired dilatations of the stoma of the cervicalesophagus. In January 1966 a subphrenic abscesswas drained and gastrostomy performed for de-compression. Later in April a subtotal gastrectomywas performed for a large gastric ulcer. Stagedsubsternal right ileocolonic bypass was performedon June 23, 1966 with the establishment of acervical ileostomy. On July 21 the cervical esopha-gus was anastomosed to the ileum in the neckusing the seromuscular cuff technic. Mucosa ofthe ileum was excised for a distance of 3 cm. andthe stenosed esophageal stoma was sutured to themucosal-submucosal edge. The cuff was thentacked over scarred esophageal wall. On the ninthpostoperative day a fistula developed at the cervi-cal anastomosis, but this closed in five days. Thepatient is now eating well and receiving weeklydilatations of the esophageal stoma.

Case 5. F. P., a 39-year-old woman had intra-peritoneal accumulation of bile after cholecystec-tomy. At reoperation two separate stumps of theright hepatic duct were found embedded in hilarscar tissue. No bile channel to the left lobe wasidentified. An attempt was made to anastomosedistal common duct to the rim of these two open-ings. This procedure failed. At reoperation awedge of the left hepatic lobe was excised anda Roux-en-Y loop of jejunum was sutured to therim of the cut surface of the liver. This establishedpartial drainage and improvement for severalmonths. There was no leakage. An additionaloperation was done in an attempt to drain theright lobe in a similar manner. The patient suc-cumbed because of hepatic necrosis, secondary tointerruption of the blood supply to this portionof the liver.

Case 6. T. M., a 62-year-old woman was op-erated upon 2-4-64 for carcinoma of the antrumof the stomach. A radical gastrectomy includedomentum and 2 to 3 cm. of duodenum. It wasbelieved that more duodenum could be resectedby avoiding the inversion of the stump. A sero-

muscular cuff of duodenum was prepared andmucosa was closed with a continuous 000 chromiccatgut suture. The muscle layer was apposed withinterrupted 000 chromic catgut sutures. The endof duodenum was closed with interrupted silksutures. The operative area healed normally andshe is doing well.

Summary

A method for safer anastomosis of jeju-num to esophagus or to other organs hasbeen described. The basic principles ofmaintaining intact vascular channels andobtaining accurate approximation of themucosa-submucosa are incorporated. Ex-perimental observations and initial clinicalexperiences support the conclusion that theinner aspect of denuded jejunal muscle ad-heres well and heals satisfactorily whenanastomosed to esophagus, or other organsor tissues. Tubular seromuscular cuffs ofstomach, duodenum and ileum have servedfor easier and safer anastomoses.

AcknowledgmentThe authors thank C. Elton Cahow, M.D., for

the use of Case 4; Joseph J. Ventimiglia, M.D.,and Mr. Thomas House for medical illustrations;and Mr. Harry Asadoorian for his cooperation inproducing the photographic illustrations.

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