Obstruction of the proximal jejunal loop following gastrectomy: Mechanism and prevention

Abstract

Much has been written about obstruction of the outlet or distal loop following gastrectomy. However, the complication of proximal or duodenal loop obstruction has received very little discussion and is therefore not generally known. Although obstructions of the distal or efferent loop may be well tolerated by patients for long periods with proper water and electrolyte balance, obstructions of the proximal loop result in a closed loop or potentially strangulating obstruction and are very poorly tolerated. Patients in whom this complication develops can die from hyperthermia thirty-six to seventy-two hours postoperatively. The syndrome has been reproduced experimentally. 20 This serious and often rapidly fatal complication can be avoided. The proximal loop should not be too short to prevent kinking and rotation at the stoma. On the other hand, the proximal loop should not be too long because it may become “water-logged” with bile, pancreatic juice and duodenal secretions. The heavy, distended loop can thus kink at the stoma and likewise obstruct the distal loop. Since it is almost impossible always to estimate the correct length of the proximal loop and to avoid tensions and torsions at the stoma, a supplementary enteroanastomosis should be established after the resection as an added safeguard. It serves the important function of evacuating the proximal loop and relieves pressure within the duodenum and on the duodenal stump. It is a useful but neglected procedure.