Gastroenterostomy for Pyloric Stenosis—A Comparison of Endosonographic, Surgical, and Endoscopic Procedures in Surgical Treatment

A gastroenterostomy is a surgical procedure to create a connection between the stomach and the small intestine. It is typically performed to treat obstruction in the gastrointestinal tract. There are various indications for a gastroenterostomy.

A gastroenterostomy is generally performed in two situations:

To reconstruct the gastrointestinal passage following resection of the stomach. These are surgeries in which a portion of the stomach has been removed. Resection of the stomach is performed, for example, to treat

• peptic ulcer disease (stomach ulcer),
• gastric or duodenal bleeding, or
• tumor disease (stomach cancer).

As a bypass procedure between the stomach and the small intestine without gastric resection, for example,

• in cases of inoperable tumors or
• as part of bariatric surgery (weight-loss surgery).

Medical professionals distinguish between two methods of resective gastroenterostomy:

• Billroth I resection
• Billroth I resection

Billroth I resection

The surgeon resects 2/3 of the stomach, i.e., he removes two-thirds of the stomach. He then anastomoses the gastric stump to the duodenum. The original passage from the stomach to the duodenum is preserved (see Figure f).

Types of Gastroenterostomy

Billroth II resection

Here, too, the surgeon resects two-thirds of the stomach. The duodenum is closed off at its upper end. The gastrointestinal passage can be restored using two methods:

• according to Schloffer, or
• as a Roux-Y anastomosis.

Schloffer gastroenterostomy (see Figure c): A double-lumen jejunal loop (small intestine loop) is pulled up to the stomach. In this reconstruction, the two legs of the loop—the raised loop—must be connected at their base. Digestive juices from the pancreas and bile can flow through this connection into the lower sections of the small intestine. This prevents reflux into the stomach.

The Roux-Y reconstruction (see Figure e): In a Roux-Y gastric bypass, the surgeon transects the upper small intestine (jejunum) approximately 40 cm beyond its junction with the duodenum. The surgeon connects the outgoing limb to the stomach via a gastroenterostomy. Digestive juices flow from the duodenum through the upper portion of the transected small bowel loop. This portion is anastomosed laterally to the loop that has been pulled up to the stomach.

A gastroenterostomy can serve to reroute the passage of food when the natural passage is disrupted or blocked. This can be the case, for example, with inoperable tumors of the lower stomach or the duodenum.

The food passage is usually established via a side-to-side anastomosis. In this procedure, an upper small bowel loop is pulled up to the tumor-free portion of the stomach and connected by sutures (see Figures a and b).

A special form of gastroenterostomy, in the sense of a bypass procedure, is used in bariatric surgery. Various surgical techniques are employed here to reduce the size of the stomach or to perform gastric bypass surgery.

Normally, the chyme passes from the esophagus into the stomach and then into the small intestine, where the components of the chyme are broken down © bilderzwerg | AdobeStock

The altered gastrointestinal passage can lead to gastric emptying that is either accelerated or delayed. The following syndromes are distinguished:

Dumping syndromes: These occur primarily following Billroth II resections. A distinction is made between early dumping and late dumping syndromes:

• Early dumping: A sudden emptying of hyperosmolar chyme into the small intestine approximately 15 to 30 minutes after food intake. This causes a shift in fluid balance within the intestinal lumen, resulting in a drop in blood pressure.
• Late dumping: This involves a reactive, excessive release of insulin triggered by carbohydrates ingested with food. The excess insulin can lead to a hyperglycemic phase and even symptoms of shock.

Loop syndromes: Following a gastroenterostomy, the drainage of bile and pancreatic secretions is impaired. This results in a buildup of misdirected food residues and bacterial overgrowth. The consequences are

• vomiting,
• loss of appetite, and
• diarrhea.

Medical professionals distinguish between two forms: afferent loop and efferent loop. The cause lies in the absence of a connection between the two segments of the small intestine. Treatment ultimately involves reconstructive surgery to create a Billroth I, Billroth II, or Y-Roux-en-Y gastrectomy.

Other complications following gastric resections include:

• Exocrine pancreatic insufficiency
• Anastomotic ulcers
• Anastomotic stricture
• Bacterial overgrowth / blind-loop syndrome
• Pernicious anemia
• Lactose intolerance

Patients should eat 6 to 12 small meals a day after surgery. Eat slowly and chew thoroughly. This allows the salivary enzymes in the mouth to participate in the digestive process.

In addition, vitamin B12 supplementation should be administered, and a gastroscopy should be performed for monitoring purposes.

What is a gastroenterostomy?

A gastroenterostomy is an anastomosis—that is, an artificially created connection—between the stomach and the small intestine. This procedure allows food to pass directly from the stomach into the small intestine. A gastroenterostomy is performed when there is a narrowing in the area of the pylorus or duodenum that obstructs normal passage.

When is a gastroenterostomy necessary?

A gastroenterostomy is often indicated in cases of pyloric stenosis or malignant pyloric stenosis. The cause may be a tumor that narrows the pylorus or the duodenum. A gastroenterostomy may also be performed as a palliative measure to alleviate symptoms of delayed gastric emptying and enable food intake.

What is an endosonographic gastroenterostomy?

Endosonographic gastroenterostomy is a modern endoscopic procedure. Using endosonography and endoscopy, a loop of the small intestine is identified, and a LAMS (Lumen-Apposing Metal Stent) is then inserted. This metal stent creates a direct connection between the stomach and the small intestine. The procedure is also known as EUS-GE and represents a minimally invasive alternative to surgical gastroenterostomy.

How is an endoscopic gastroenterostomy performed?

In endoscopic gastroenterostomy, a wire or balloon is positioned under endoscopic guidance. This is followed by the placement of a metal stent, specifically a lumen-apposing metal stent. This allows food to bypass the stricture. Endoscopic procedures often avoid the need for major surgery and enable a quick recovery.

What are the advantages of gastroenterostomy over duodenal stents?

Both duodenal stents and gastroenterostomy are used to treat pyloric stenosis. Studies compare endoscopic procedures with traditional stents in terms of long-term success and function. In many cases, gastroenterostomy can provide a more permanent solution, as the connection between the stomach and the small intestine completely bypasses the narrowing. The decision is made on a case-by-case basis by specialists in gastroenterology and surgery.