Background
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.
Indications
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. [1] 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. [2, 3] A meta-analysis (17 studies) by Del Nero et al compared surgical gastrojejunostomy (GJJ) with endoscopic stenting (ES) for palliation of malignant GOO. [4] The techniques were assessed with respect to efficacy, safety, duration of hospitalization, and survival. ES was found to result in earlier oral refeeding, a shorter duration of hospitalization, and a lower incidence of complications; however, GJJ resulted in a lower rate of recurrence of obstructive symptoms and longer overall survival.
For patients with morbid obesity, a Roux-en-Y gastrojejunostomy (gastric bypass) may be performed, which serves as a restrictive procedure with some malabsorption. [5, 6] Roux-en-Y gastric bypass (RYGB) 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 RYGB. [7]
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. [8]
Contraindications
Gastrojejunostomy is contraindicated in patients who are unfit for general anesthesia.
Relative contraindications for gastrojejunostomy include the following:
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Conditions that increase the risk of anastomotic leakage (eg, poor nutritional status with severe hypoalbuminemia or disseminated malignancy with severe ascites or diffuse peritoneal deposits)
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Diffuse peritonitis and severe sepsis (diffuse peritonitis per se is not a contraindication)
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Extensive gastric varices
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Laparoscopic approach in patients with a past history of operations in the upper abdomen (the presence of adhesions and the altered anatomy may complicate the procedure)
Technical Considerations
Best practices
Preoperative optimization, especially adequate hydration with correction of electrolyte imbalance and gastric lavage, prevents postoperative complications.
Appropriate positioning of a 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.
A systematic review and meta-analysis (six observational studies; two randomized controlled trials [RCTs]) by Hajibandeh et al compared closure of the mesenteric defect with nonclosure of the defect in patients undergoing laparoscopic RYGB (LRYGB) with gastrojejunostomy for morbid obesity. [9] The results suggested that closure of mesenteric defects in LRYGB with gastrojejunostomy may be associated with lower risks of internal herniation and reoperation for small-bowel obstruction than nonclosure of the defects.
A retrospective clinical and numerical simulation study (N = 73) by Zhang et al compared stomach-partitioning gastrojejunostomy (SPGJ) with conventional gastrojejunostomy (CGJ) for treating GOO. [10] The techniques were assessed with respect to surgical outcomes, postoperative recovery of GI function, delayed gastric emptying (DGE), and nutritional status. SPGJ was found to have significant advantages over CGJ in terms of time to pass gas (3 vs 4 d), time to oral intake (3 vs 4 d), postoperative hospitalization (7 vs 9 d), DGE incidence (2.1% vs 36%), DGE grading, and complications.
Procedural planning
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. [11]
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. [12]
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 [13] ; 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. [14, 15, 16] 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. [17]
Complication prevention
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.
Outcomes
When RYGB is performed for the purposes of metabolic surgery, it carries a risk of marginal ulceration, which may necessitate elective or emergency surgery if perforation occurs. A study by Wynn et al (N = 43) assessed characteristics associated with elective (n = 24) vs emergency (n = 19) presentations for marginal ulcer following RYGB. [18] Patients with emergency presentations were less likely to have bleeding episodes (0% vs 33%) and strictures (16% vs 46%) but were more likely to require admission to the intensive care unit (ICU; 32% vs 4%) and to have a longer median length of stay (2 vs 5 d).
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Handsewn gastrojejunostomy. First layer of anastomosis comprises of interrupted seromuscular sutures (Lembert) between stomach and the jejunum.
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Handsewn gastrojejunostomy. Second layer in progress, continuous suture all coats between cut ends of stomach and jejunum.
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Handsewn gastrojejunostomy. Third layer in progress, continuous all coats loop-on-mucosa sutures between cut ends of stomach and jejunum.
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Handsewn gastrojejunostomy. Third layer completed of continuous all coats sutures between stomach and jejunum. Note no mucosa eversion is present, which is the hallmark of loop-on-mucosa technique of sutures.
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Handsewn gastrojejunostomy. Fourth (last) layer of anastomosis comprises of Lembert sutures between stomach and the jejunum.
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Subtotal gastrectomy in progress. Linear stapler used to staple the first part of the duodenum during subtotal gastrectomy.
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Subtotal gastrectomy in progress. Linear cutter being used to section and staple the stomach from the lesser curve side.
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Subtotal gastrectomy in progress. Partially stapled stomach from the lesser curve side.
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Subtotal gastrectomy. Following partially stapled stomach from the lesser curve side, handsewn gastrojejunostomy in progress. Note that full length gastrojejunostomy on the cut end of the stomach is not carried out.
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Subtotal gastrectomy. Gastrojejunostomy anastomosis complete, combination of stapled and handsewn technique.
