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Gastrojejunostomy

Gastrojejunostomy

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Gastrojejunostomy is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum. This is usually done either for the purpose of draining the contents of the stomach or to provide a bypass for the gastric contents. Gastrojejunostomy can be done via either an open or a laparoscopic approach. Percutaneous gastrojejunostomy may be performed, in which a tube is placed through the abdominal wall into the stomach and then through the duodenum into the jejunum. In this article, we describe the indications, techniques, and complications of gastrojejunostomy.

Rydygier, a Polish surgeon, is credited with the first attempt at gastroenterostomy in 1881, which was carried out with chloroform anesthesia in a patient with duodenal ulcer. [1]  However, the patient developed circulatory failure and died 12 hours later.

The first successful gastroenterostomy (gastroduodenostomy) was carried out by Theodor Billroth in 1881. It was performed in a patient with carcinoma of the stomach following partial gastrectomy. [2]

Later that year, while operating on a case of pyloric carcinoma, Wolfer noted extension of the growth into the pancreas. Because gastrectomy was not possible, he went on to perform the first successful palliative gastrojejunostomy. [3]

When Billroth attempted the same procedure, his patient succumbed to symptoms and postmortem findings of what is today known as afferent loop syndrome. To avoid this complication, the technique of the Roux-en-Y anastomosis was introduced by Wolfer in 1883 and later popularized by Cesar Roux of Lausanne in 1887. [4]

In 1885, when Billroth encountered a large pyloric tumor during laparotomy, instead of a gastroduodenostomy, he anastomosed a loop of jejunum to the stomach proximal to the growth because the patient was not fit for primary resection (as a consequence of malnourishment secondary to gastric outlet obstruction). [5]  In the second stage, Billroth resected the tumor and closed the cut ends of stomach and duodenum, which was described by von Hacker as Billroth II partial gastrectomy. [5]

In 1888, Kroenlein unsuccessfully attempted to modify the Billroth II partial gastrectomy by anastomosing the side of jejunum directly to the cut end of the stomach. [3]  One year later, von Eiselsberg performed the same procedure successfully, and in the following years, this operation was modified by Mikulicz, Reichel, Polya, and Finsterer. [3, 6]  The Polya gastrectomy is a commonly performed alternative to Billroth II procedure.

One the basis of his anatomic studies, Petersen recommended an anastomosis of the high jejunal loop to the posterior surface of the stomach to avoid the long looped Roux-en-Y anastomosis. This technique forms the basis of the posterior gastroenterostomy procedure done today. [3, 7]

Alongside new techniques, surgeons also began to study and describe the various complications encountered. In 1899, Braun described the first jejunal ulcer resulting from a gastroenterostomy. [3]  In 1913, a paper on the unfavorable effects of gastroenterostomy was presented by Hertz. [8]  Mix coined the term dumping syndrome and described its characteristics in 1922. [3]  The use of vagotomy by Dragdtedt and Owens in 1943 was a significant milestone in peptic ulcer therapeutics. [9]  This neurosection was soon accompanied by a gastrojejunostomy to overcome the gastric stasis. This procedure is practiced today.

Gastrojejunostomy was slow to gain popularity; reports in 1884 showed that only two out of seven patients had survived the procedure. [3]  By 1900, Mayo-Robson had reported a mortality of only 16.4% in 188 consecutive cases. [3]  By the end of the 20th century, advances such as laparoscopic, percutaneous, and endoscopic gastrojejunostomy and the inclusion of the technique in bariatric procedures had been popularized. Gastrojejunostomy is now a routine procedure performed by surgeons all over the world.

Gastric outlet obstruction (GOO) is the most common indication for gastrojejunostomy. It may occur in the following clinical scenarios.

For chronic duodenal or prepyloric ulcer with pyloric scarring, one of the methods for relieving the obstruction is to perform a gastrojejunostomy along with truncal vagotomy to decrease acid production. [10]  Another alternative method is to perform vagotomy and antrectomy with the Billroth II reconstruction. Gastrojejunostomy is indicated after gastrectomy for chronic gastric ulcer refractory to medical therapy or when there is suspicion of malignancy in the gastric ulcer.

Corrosive injury of stomach with GOO is common after acid ingestion. Because of pylorospasm following corrosive ingestion, prepyloric gastric strictures are common. An alternative procedure is Billroth I gastrectomy.

For resectable carcinoma of the antropyloric region, gastrojejunostomy is performed after radical subtotal gastrectomy to maintain continuity of the gastrointestinal (GI) tract.

For nonresectable malignancies of the stomach, duodenum, or pancreatic head with GOO, gastrojejunostomy is indicated as palliative treatment. [11, 12]

For patients with morbid obesity, a Roux-en-Y gastrojejunostomy (gastric bypass) may be performed, which serves as a restrictive procedure with some malabsorption. [13, 14]  Roux-en-Y gastric bypass has been used as a rescue strategy for failed gastric banding; at follow-up of up to 10 years, it has been shown to yield results comparable to those of primary Roux-en-Y gastric bypass. [15]

Gastroparesis may be seen in patients who have diabetes or who have undergone gastric surgery. Cases unresponsive to medical management and percutaneous gastrostomy may require a subtotal gastrectomy with gastrojejunostomy to relieve symptoms. [16]

Gastrojejunostomy is contraindicated in patients who are unfit for general anesthesia.

Relative contraindications for gastrojejunostomy include the following:

Preoperative optimization, especially adequate hydration with correction of electrolyte imbalance and gastric lavage, prevents postoperative complications.

The appropriate positioning of gastrojejunostomy stoma and adequate size ensure good functional outcome.

Antecolic gastrojejunostomy is technically easy and is preferred in the setting of malignancy.

Laparoscopic gastrojejunostomy is preferred to open gastrojejunostomy when the procedure is performed for palliative purposes.

Gastrojejunostomy can be performed with a jejunal loop brought either behind the transverse colon (retrocolic) or in front of it (antecolic). The advantage of retrocolic gastrojejunostomy is a short afferent loop, resulting in decreased incidence of afferent loop syndrome. However, in a retrospective study, there was no significant difference between the two types of gastrojejunostomy with regard to long-term outcome. [17]

The antecolic position may be preferred because it is technically easy. However, when gastrojejunostomy is performed for malignant disease, whether after gastrectomy or in a palliative setting, the antecolic position is preferred to the retrocolic position.

When the retrocolic position is used, the anastomosis is at risk of obstruction owing to enlargement of the lymph nodes or serosal implants in the transverse mesocolon. In a retrocolic gastrojejunostomy, there is potential to form a gastrojejunostomy-colic fistula.

In a palliative setting, the gastrojejunostomy stoma is at risk of obstruction when a retrocolic posterior gastrojejunostomy is performed because malignancy tends to grow along the posterior gastric wall.

In a randomized trial comparing laparoscopic with open palliative gastrojejunostomy for advanced malignancies of stomach and pancreas, there was no significant difference in operating time or blood loss; however, time to start oral medications and hospital stay were shorter in the laparoscopy group. [18]

In a retrospective study, mortality, overall morbidity, operating time, time to oral solid food intake, analgesic consumption, delayed-return gastric emptying, postoperative hospital stay, and survival were not significantly different between open and laparoscopic gastrojejunostomy patients [19] ; however, estimated blood loss was significantly less and average hospital stay significantly shorter in the laparoscopy group.

At present, laparoscopic gastrojejunostomy is preferred to open gastrojejunostomy whenever possible and feasible, especially in a palliative setting for advanced malignancy.

Several studies have evaluated the feasibility and advantages of single-incision laparoscopic surgery (SILS) as compared with conventional multiport techniques for gastrectomy with gastrojejunostomy. [20, 21, 22]  Better cosmesis, decreased postoperative pain, and earlier recovery have reported. Reports have described hybrid techniques for placing gastrojejunostomy tubes in patients with distal esophageal stents in situ. Laparoscopic gastrojejunostomy tubes are inserted under endoscopic guidance so as to cause minimal manipulation of the stent itself. [23]

When performed in an elective setting, preoperative optimization of the patient (including correction of anemia, dehydration, and electrolyte imbalance with blood transfusion and adequate hydration) can prevent complications.

Adequate exposure and access, gentle handling of the bowel, appropriate positioning of the gastrotomy and enterotomy, adequate hemostasis, absence of tension at anastomosis, and good surgical technique can prevent complications.

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Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Raja Kalayarasan, MBBS, MS Associate Professor, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Disclosure: Nothing to disclose.

Bhavana Bhagya Rao, MBBS Research Trainee, Asian Institute of Gastroenterology, India

Disclosure: Nothing to disclose.

Anahita Kate, MBBS Compulsory Rotatory Intern, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Disclosure: Nothing to disclose.

Mohsina Subair, MBBS, MS (GenSurg), MRCS(Edin) Former Senior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India

Mohsina Subair, MBBS, MS (GenSurg), MRCS(Edin) is a member of the following medical societies: Association of Surgeons of India, Royal College of Surgeons of Edinburgh, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

The authors would like to thank the residents of the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, for their assistance with the images for this article, and in particular, Dr Vishnu Raveendran and Dr Raj Gopal, Postgraduates in the department.

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