Gastrojejunostomy Periprocedural Care

Updated: Jun 02, 2017
  • Author: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Preprocedural Planning

Patients with gastric outlet obstruction (GOO) may have multiple problems that might need correction before surgery. Persistent vomiting results in dehydration with loss of hydrogen, chloride, and potassium ions. This leads to hypochloremic hypokalemic metabolic alkalosis, which can be associated with paradoxical aciduria through a renal compensatory mechanism. Dehydration and electrolyte imbalance can be corrected by administering normal saline (0.9%). Once urine output is adequate, potassium can be supplemented to correct hypokalemia.

Anemia and hypoalbuminemia (if severe) require correction with blood transfusion and parenteral nutrition, respectively. Chronic longstanding GOO results in hypertrophy of gastric musculature followed by dilatation and gastric atony.

The nasogastric tube should be placed and gastric lavage performed with normal saline until returns are clear, beginning at least 5 days before surgery. Lavage should also be performed 1-2 hours before surgery. Gastric lavage removes food residue, decreases mucosal edema, and restores gastric tone.

A prophylactic antibiotic (eg, a second-generation cephalosporin) can be given at the time of induction, especially if a prolonged procedure such as gastrectomy is contemplated. Antibiotics may not be necessary when a palliative gastrojejunostomy is performed or when operations such as vagotomy with gastrojejunostomy are done for duodenal ulcer.

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Equipment

Gastrojejunostomy is performed in an operating room, which should be equipped with the following:

  • Anesthetic equipment, overhead lights, an operating table (preferably power-controlled to ensure smooth and accurate positioning, particularly during laparoscopic procedures), electrodiathermy, and suctioning systems
  • Appropriate  suture materials (commonly polyglactin and silk) and intestinal clamps
  • If laparoscopic gastrojejunostomy is contemplated, appropriate laparoscopic instruments and monitors (preferably high-definition)
  • If stapled gastrojejunostomy is planned, stapling devices, including a linear gastrointestinal anastomosis (GIA) stapler and a linear transverse anastomosis (TA) stapler
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Patient Preparation

Anesthesia

Gastrojejunostomy is performed with the patient under general anesthesia. Patients with GOO are at greater risk for aspiration of gastric contents. This risk can be reduced by emptying the stomach before induction; it can also be reduced by using rapid sequence induction technique.

Positioning

Open gastrojejunostomy is generally performed with the patient in a supine position, with the arms abducted at right angles to the body. Laparoscopic gastrojejunostomy is performed with the patient in a leg-split position. Adequate padding of pressure points should be ensured to prevent neurologic damage and pressure ulceration.

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