Anterior antecolic gastroenterostomy according to Wölfler
This technique involves bringing a loop of the jejunum to the anterior wall of the stomach anterior to the greater omentum and transverse colon. The initial loop is measured at a distance of 50 cm from the Treitz ligament, located to the left of the spine.
When fixing the loops, the following rule is observed: the afferent (small) loop is secured closer to the cardia at the lesser curvature, while the efferent (large) loop is secured closer to the pylorus at the greater curvature.
Steps for forming the anastomosis:
- Placement of the posterior row of seromuscular sutures with trimming of excess threads.
- Opening the lumen of the stomach and intestine with a 0.75 cm margin.
- Drying the lumen and aspirating the contents.
- Placement of a continuous catgut suture on the posterior lips of the anastomosis.
- Formation of the anterior lips using the inverting Schmieden suture after changing instruments.
- Completion with a second row of clean interrupted silk seromuscular sutures.
Posterior retrocolic gastroenterostomy according to Hacker — Petersen
This surgical option requires an approach through the mesentery of the transverse colon (mesocolon transversum). The incision is made vertically below the Riolan arch in an avascular zone.
Features of the technique:
- A jejunal loop 7–10 cm long from the flexura duodenojejunalis is selected for the anastomosis.
- The posterior wall of the stomach is brought out through the created opening in the mesentery.
- Stay sutures are placed between the stomach and the small intestine.
- The edges of the mesenteric incision are fixed with interrupted sutures to the gastric wall above the anastomosis to prevent strangulation.
The anastomosis is formed in a side-to-side fashion, and the afferent loop is additionally sutured to the gastric wall above the stoma to prevent motility disorders.
Braun enteroenterostomy and vicious circle syndrome
To prevent the development of vicious circle syndrome (circulus vitiosus), an additional stoma is created between the jejunal loops. Braun enteroenterostomy is performed in a side-to-side fashion 10–15 cm distal to the main stoma.
The essence of afferent loop syndrome and the vicious circle is impaired evacuation: food is retained in the stomach and the afferent limb, stretching it and compressing the efferent loop. This leads to belching, vomiting, and is often combined with dumping syndrome. Treatment in such cases requires reconstructive surgery, including takedown of the stoma and antrectomy (pyloroantral resection).
Briefly: answers to topical questions
Which layers of the gastric and intestinal wall are pierced when placing the Schmieden suture on the anterior lips of the anastomosis?
When placing the Schmieden suture on the anterior lips of the anastomosis, all layers of the gastric and intestinal wall are pierced. This is a full-thickness inverting suture where the thread passes strictly in one direction:
- Mucosa — from the organ lumen side (entry point).
- Serosa — on the outer surface (exit point).
The thread always runs from the inside outwards (mucosa → serosa), so that when the suture is tightened, the wound edges are inverted into the lumen, bringing their serosal surfaces into contact.
What specific complications, besides afferent loop syndrome and dumping syndrome, can occur after gastroenterostomy?
In addition to afferent loop syndrome and dumping syndrome, sources describe the following conditions:
- Vicious circle syndrome (Circulus vitiosus) — impaired evacuation with food retention in the stomach, duodenum, and the afferent limb of the jejunum.
- Inadvertent gastroileostomy (Inadvertent gastroileostomy) — erroneous creation of an anastomosis with the ileum instead of the jejunum.
- Efferent loop obstruction (Efferent loop obstruction) — associated with spasm and inflammation.
- Following retrocolic gastroenterostomy, afferent loop obstruction is possible due to its herniation through a defect in the mesocolon.
Loop fixation rule: AL (Afferent — Lesser curvature) and EL (Efferent — Greater curvature).
Class and exam questions
What are the main indications for gastroenterostomy?
The operation is performed for unresectable cancer of the pyloric part of the stomach, as well as for cicatricial pyloric stenosis in severely debilitated patients.
What is the difference between the loops in Wölfler anastomosis?
The afferent loop is measured at a distance of 50 cm from the Treitz ligament and fixed at the lesser curvature, while the efferent loop is fixed at the greater curvature of the stomach.
What is the purpose of Braun anastomosis?
An additional interintestinal stoma is created to prevent vicious circle syndrome and normalize content evacuation.
What else to study on this topic
- Anatomical landmarks of the transverse mesocolon and the Riolan arch
- Technique of Schmieden suture placement in stoma formation
- Pathogenesis of dumping syndrome and hypoglycemic states
- Features of Billroth I gastrectomy in reconstructive interventions
- Rules for instrument change and surgical glove protocol when opening organ lumens
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Gastroenterostomy" and 2,777 more subject pages
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the "Abdominal Surgery" section
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.