Gastrojejunostomy Technique

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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Technique

Creation of Gastrojejunal Anastomosis

Incision and exposure

A midline incision extending from the xiphoid to the umbilicus is commonly used. Additional exposure can be obtained by excising the xiphoid above and extending the incision below the umbilicus. Self-retaining retractors improve exposure. Obtaining adequate exposure in a gastrojejunostomy is not a major problem, in that the majority of the structures involved in the operation are mobile.

Gastrojejunostomy with stomach in situ

In an antecolic anterior isoperistaltic gastrojejunostomy performed to the native stomach, the jejunal loop is brought anterior to the transverse colon, and the anastomosis is carried out to the anterior wall of the stomach in a side-to-side manner.

The first step is to mark the stoma in the anterior wall of the stomach. When the procedure is being performed for an unresectable malignancy, the gastrotomy should be placed at least 4 cm away from the proximal extent of the tumor close to the greater curvature. When it is being performed for ulcer disease, the gastrotomy should be placed within 3-5 cm from the pylorus and close to the greater curvature to improve gastric emptying. Care should be taken to ensure that the stoma is not made high on the greater curvature because such positioning can result in an intractable bile reflux with poor gastric emptying.

The jejunal loop, approximately 10-15 cm from the duodenojejunal flexure, is held with a Babcock clamp, with the distal jejunum close to the pylorus of the stomach and the proximal jejunum. That is, the jejunal loop is close to the duodenojejunal flexure and away from the pylorus, so that the anastomosis is made in an isoperistaltic fashion. The jejunal loop is brought anterior to the transverse colon.

A noncrushing bowel clamp is placed on the jejunum, close to the mesenteric side but not over the mesentery, with the handle of the clamp towards the patient’s right side and the proximal jejunum towards the toe end of the clamp. Another bowel clamp is placed on the stomach in a similar fashion. The bowel clamps are held together and, if necessary, can be kept in apposition by using ligatures.

Posterior seromuscular (Lembert) stitches are taken from the antimesenteric border of the jejunum to the gastric wall in an interrupted fashion with 3-0 silk. Any type of nonabsorbable suture material, including linen, can be used for this layer. The sutures are tied sequentially, and angle sutures are kept long and held with a hemostat. This forms the outer posterior layer.

A gastrotomy approximately 5 cm long is made approximately 0.5-1 cm from the seromuscular layer. A scalpel is used to incise the seromuscular layer, and the lumen is entered at one point, with the cutting end of the scalpel facing up to prevent accidental damage to the posterior layer. Once the lumen is entered, scissors are used to complete the mucosal incision. Bleeding from the cut surface is controlled with cauterization or transfixation with 4-0 silk.

The jejunum is cut in a similar fashion. The jejunotomy should be slightly shorter than the gastrotomy because the small-bowel mucosa has a tendency to stretch. While the enterotomy and gastrotomy are made, spillage of bowel contents is avoided by applying suction and keeping mops around the bowel.

Full-thickness posterior layer stitches are taken with 3-0 polyglycolic acid sutures. Suturing is facilitated by holding the anterior gastric and jejunal wall with a Babcock clamp and retracting away. One more Babcock clamp is used to hold the two posterior layers in apposition. Initially, a Connell stitch is taken at one end, commonly through the end closest to the surgeon. A Connell stitch is taken by entering the lumen of the jejunum from the outside in, with the needle exiting on the same side from within the jejunal lumen to outside 2-3 mm away (adjacent to the stomach) from the site of entry.

The needle is then crossed over and enters the stomach from outside in and then from within out (away from the jejunal wall) from the stomach lumen wall. The suture is tied so that the knot lies outside the lumen, and the free end of the thread is kept long and held with a hemostat. The needle enters the jejunal lumen from outside in, and the posterior layer is completed by taking full-thickness continuous interlocking stitches. An assistant should hold the suture and maintain sufficient tension to ensure hemostasis, but the tension should not be so high that it strangulates the tissue. This forms the inner posterior layer.

Once the other end is reached, a Connell stitch is taken, and the same procedure is repeated to complete the anterior full-thickness stitches. Halfway through the anterior layer, the intestinal clamps on the jejunum and the stomach are released to check for bleeding from the anastomotic line. If bleeding is present, it is controlled by taking full-thickness stitches with a separate suture. Once the near end is reached, sutures are tied to complete the inner anterior layer. The anterior seromuscular layer is completed by taking interrupted Lembert stitches with 3-0 silk. The patency of the stoma is checked by means of palpation.

Gastrojejunostomy after gastrectomy

After a subtotal gastrectomy, an end-to-side gastrojejunostomy can be performed in which the whole of the gastric stump is anastomosed to the side of the jejunal loop. After the section of the stomach, distal to the pylorus at the level of the first part of the duodenum, the jejunal loop (~10-15 cm from the duodenojejunal flexure) is brought up to the stomach in an antecolic position.

To create an isoperistaltic anastomosis, the afferent loop of the jejunum should be close to the lesser curvature and the efferent loop close to the greater curvature. A noncrushing bowel clamp is placed on the jejunum close to the mesenteric side but not over the mesentery, with the handle of the clamp towards the patient’s right side and the proximal jejunum towards the toe end of the clamp. Another bowel clamp is placed on the stomach in a similar fashion after the nasogastric tube is withdrawn appropriately.

Interrupted Lembert seromuscular stitches using 3-0 silk are placed between the antimesenteric end of jejunum and the posterior gastric wall at the level of the proposed section of the stomach for subtotal gastrectomy (see the image below).

Handsewn gastrojejunostomy. First layer of anastom Handsewn gastrojejunostomy. First layer of anastomosis comprises of interrupted seromuscular sutures (Lembert) between stomach and the jejunum.

Ideally, this layer should be taken before the stomach is divided; it is technically difficult to take this layer after gastric resection has been carried out. The sutures are tied sequentially, and angle sutures are kept long and held with a hemostat. This forms the posterior outer layer. It is preferable to include the whole of the gastric stump in the anastomosis, as described for a Polya-type reconstruction, though this may be done in an antecolic manner.

A slightly smaller incision than the length used for the gastric stump is made in the jejunum with a knife, approximately 5-10 mm lateral to the seromuscular stitches. The clamp should be placed close to the mesentery, with care taken not to include the mesentery. Two Babcock clamps are placed, one on each anterior wall, to expose the posterior gastric and jejunal walls.

The posterior inner layer is begun by taking a Connell stitch at the near end with 3-0 polyglycolic acid suture. The Connell stitch is taken by entering the jejunal side from the outside in, with the needle exiting on the same side 2-3 mm away from the site of entry. The needle is then crossed over, enters the stomach from the outside in, and then comes out from the stomach wall. The suture is tied so that the knot lies outside the lumen. The free end of the thread is kept long and held with a hemostat. After entering the jejunal lumen from the outside in, full-thickness continuous interlocking stitches are taken through both edges (see the image below).

Handsewn gastrojejunostomy. Second layer in progre Handsewn gastrojejunostomy. Second layer in progress, continuous suture all coats between cut ends of stomach and jejunum.

The needle must be pulled through each edge separately to ensure a full-thickness bite on both edges. This forms the posterior inner layer. Once the far end is reached, a Connell stitch is taken, and an anterior inner layer is completed by taking it continuously through and through stitches. A loop-on-mucosa suture technique is followed, in which the suture is taken from the inside of the jejunal wall out and from the outside in through the stomach wall, with the pull on the suture being within the lumen (see the image below).

Handsewn gastrojejunostomy. Third layer in progres Handsewn gastrojejunostomy. Third layer in progress, continuous all coats loop-on-mucosa sutures between cut ends of stomach and jejunum.

This technique ensures good inversion of the mucosa (see the image below). Inversion can also be achieved by taking a small amount of mucosa and a large part of the seromuscular layer.

Handsewn gastrojejunostomy. Third layer completed 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.

Once half of the anterior inner layer is completed, the clamps are released to confirm the absence of bleeding from the posterior layer. If bleeding points are identified, they are controlled by taking interrupted full-thickness stitches through both edges. The anterior inner layer is completed by tying with the free end of the thread on the near end. The double-layer anastomosis is completed with an anterior seromuscular layer of interrupted silk 3-0 sutures (see the image below).

Handsewn gastrojejunostomy. Fourth (last) layer of Handsewn gastrojejunostomy. Fourth (last) layer of anastomosis comprises of Lembert sutures between stomach and the jejunum.

This technique is similar to the Kroenlein modification of the Billroth II gastrectomy. In the original Billroth II procedure, the gastric stump is closed, and a side-to-side gastrojejunostomy is fashioned by making a separate gastrotomy posterior to the gastric stump.

Other modifications of the Billroth II gastrectomy commonly used are the Polya technique, which is similar to the Kroenlein modification but positions the jejunal loop in a retrocolic fashion. In the Von Eiselsberg modification (also known as a gastrojejunostomy with valve), the gastric stump is partly closed, and the remaining stump is used for the anastomosis. The Hoffmeister modification resembles the Von Eiselsberg technique, but the jejunal loop is brought up in a retrocolic fashion.

Stapled gastrojejunostomy

Stapled side-to-side antecolic gastrojejunostomy with stomach in situ

The jejunal loop, approximately 10-15 cm from the duodenojejunal flexure, is brought up to an antecolic position. The antimesenteric edge of the jejunum and stomach wall close to the greater curvature are kept in apposition by taking two seromuscular stay sutures at each end and one in the center. Alternatively, the sites marked for the anastomosis can be temporarily held by a pair of Babcock clamps. A small (~1-2 cm) enterotomy is made in an anterior gastric wall and the antimesenteric edge of the jejunum with the electrocautery. The branches of the linear cutting (gastrointestinal anastomosis [GIA]) stapler, which have two rows of staples and a blade between them, are placed through the openings.

Once the stapler is in place, care should be taken to ensure that the mesentery is not caught between the branches of the stapler. The stapler is fired to complete the anastomosis. Through the enterotomy, the staple line is visually inspected for evidence of any bleeding. If present, bleeding should be controlled with hemostatic stitches. Cauterization should not be used to secure hemostasis, because it can cause transmission of heat energy through the normal bowel wall, resulting in thermal damage.

The enterotomy is closed in two layers with 3-0 polyglycolic acid and 3-0 silk. Alternatively, a linear stapler can be used to close the enterotomy and complete the anastomosis.

Stapled antecolic gastrojejunostomy after subtotal gastrectomy

The first part of the duodenum is stapled and sectioned about 2 cm distal to the pylorus with a linear stapler (see the image below). Usually, a 30-mm linear stapler is employed for this procedure.

Subtotal gastrectomy in progress. Linear stapler u Subtotal gastrectomy in progress. Linear stapler used to staple the first part of the duodenum during subtotal gastrectomy.

Handsewn anastomosis after partial transection of stomach for subtotal gastrectomy with linear cutter

A linear cutter is used to staple and section the stomach at the desired level (see the image below).

Subtotal gastrectomy in progress. Linear cutter be Subtotal gastrectomy in progress. Linear cutter being used to section and staple the stomach from the lesser curve side.

At this point, complete transection of the stomach is done with a linear cutting stapler, followed by a stapled gastrojejunal anastomosis, as described below. The alternative is partial transection of the stomach with stapling. The remaining stomach is transected and anastomosed to the jejunum with a handsewn technique (see the image below).

Subtotal gastrectomy in progress. Partially staple Subtotal gastrectomy in progress. Partially stapled stomach from the lesser curve side.

In this technique, the entire of the gastric stump is not anastomosed to the jejunum, as mentioned earlier; only the part that is not stapled is used for the anastomosis (see the images below).

Subtotal gastrectomy. Following partially stapled 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.
Subtotal gastrectomy. Gastrojejunostomy anastomosi Subtotal gastrectomy. Gastrojejunostomy anastomosis complete, combination of stapled and handsewn technique.

Stapling after complete transection of stomach for subtotal gastrectomy with linear cutter

In this technique, the gastric stump is held with a Babcock clamp and lifted up so that the posterior gastric wall is visualized. A jejunal loop, approximately 10-15 cm from the duodenojejunal flexure, is brought up in an antecolic position. The site of anastomosis in the gastric wall should be at least 3 cm away from the gastric stump (staple line).

The antimesenteric edge of the jejunum and the posterior gastric wall are kept in apposition by two seromuscular stay sutures (one at each end). An enterotomy of approximately 1-2 cm is made in the stomach wall closer to the greater curvature of the stomach, and a similar opening is made in the antimesenteric edge of the jejunal wall. The enterotomies must face each other to avoid deformation of the anastomosis.

The branches of the linear cutter are inserted through the openings. The stapler is fired to complete the anastomosis. The enterotomy is closed in two layers with 3-0 polyglycolic acid and 3-0 silk. Alternatively, the linear stapler can be used to complete the anastomosis. If the linear stapler is used to close the opening, the superfluous tissue of the anastomosis is removed with a scalpel.

Robotic gastrojejunostomy

The use of robotic surgery in advanced gastrointestinal procedures is increasing. The potential advantages of robotic surgery over laparoscopic surgery include the following [24] :

  • Superior three-dimensional vision
  • Wristed instrumentation, which overcomes the fulcrum effect seen with traditional laparoscopic instruments
  • Optimized ergonomics
  • Tremor filter

These advantages could result in improved dissection and suturing, whereby a handsewn gastrojejunostomy could be performed with high accuracy.

In a systematic review of robotic surgery published in 2012, robotic gastrojejunostomy and laparoscopic gastrojejunostomy (Roux-en-Y gastric bypass) in bariatric surgery were compared and analyzed. [25]  Eight studies with a total of 1750 patients were included in the analysis. The mean operating time was higher in the robotic group than in the laparoscopic group (192 vs 173 min). The overall mean complication rate was 7.9% in the robotic group and 8.6% in the laparoscopic group. A shorter hospital stay in the robotic group was reported in one of the studies.

However, in a prospective nonrandomized controlled study, robotic gastrojejunostomy (Roux-en-Y gastric bypass) was associated with a higher incidence of anastomotic and bleeding complications. [26]  Loss of haptic tactile feedback and increased pressure on the abdominal wall resulting in abdominal wall vessel injury were possible reasons for increased complications in the robotic group.

Although robotic surgery shows promise, large and well-designed randomized studies will be required to determine whether it is superior to laparoscopic surgery in this setting. [27, 28, 29]

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Complications

The incidence and severity of complications after gastrojejunostomy have been markedly reduced in the past few decades as a consequence of improvements in technique. These complications can be broadly divided into postoperative syndromes and postgastrectomy syndromes; the latter can be further subdivided into complications secondary to gastric resection and complications related to reconstruction.

Postoperative syndromes

Postoperative syndromes may include the following:

  • Secondary hemorrhage
  • Leakage from the anastomosis
  • Duodenal stump blowout
  • Infection
  • Anastomotic stricture

If bleeding manifests through the abdominal drain, it is usually due to slippage of ligatures. [30]  If it is significant and persistent, reexploration for hemostasis may be warranted. If bleeding manifests through the nasogastric tube aspirate, anastomotic line bleeding is indicated. This is initially managed conservatively by means of gentle gastric lavage with normal saline, blood transfusion, and close monitoring of vital parameters. If bleeding is persistent, surgical exploration is required. The anterior layer of the gastrojejunostomy is opened, and the cause of the bleeding is assessed.

Usually, bleeding manifests from the posterior anastomotic line and is controlled by taking hemostatic sutures followed by resuturing of the anterior layer of the gastrojejunostomy. If bleeding occurs from the anterior layer, resuturing of the layer controls the bleed.

Leakage from the anastomosis usually occurs around postoperative day 4-7 and is associated with high morbidity and mortality. [30]  It requires reexploration, drainage, and a feeding jejunostomy.

Duodenal stump blowout is a devastating complication following Billroth II gastrectomy, which usually occurs around postoperative day 5. If the drain is in situ, duodenal stump blowout manifests as increased bile output from the drain; if the drain is not in situ, it can manifest as a localized intra-abdominal collection or diffuse peritonitis. If the drain is already in situ and draining well without any signs of peritonitis, conservative treatment (nil per os [NPO], antibiotics, and total aprenteral nutrition or jejunostomy feeds) may be tried; this may allow resolution of fistula.

Any signs of peritonitis necessitate prompt reoperation, lavage, and drainage with a feeding jejunostomy. A tube duodenostomy can be used to make a controlled duodenal fistula.

Anastomotic stricture is a delayed complication that is common when gastrojejunostomy is performed to treat corrosive injury of the stomach with gastric outlet obstruction (GOO) or as a palliative procedure for malignancy. Initial endoscopic management with balloon dilatation can be attempted; if this fails, surgical exploration and revision of anastomosis are required.

Postgastrectomy syndromes secondary to gastric resection

Postgastrectomy syndromes secondary to gastric resection include the following:

  • Dumping
  • Metabolic disturbances
  • Colic
  • Weight loss
  • Asthenia

Clinically significant dumping syndrome with characteristic alimentary and cardiovascular manifestations occurs in approximately 10-20% of patients after gastrojejuonostomy. It is the most common and often disabling postgastrectomy syndrome. [31, 32]  Depending on the time elapsed between the intake of a meal and the appearance of symptoms, it is classified as either early dumping syndrome or late dumping syndrome.

Early dumping syndrome symptoms occur 30-60 minutes postprandially. [31, 32]  The rapid emptying of osmotically active gastric contents into the duodenum causes a shift of fluid from the intravascular compartment into the bowel lumen, leading to distention and increased frequency of bowel contractions.

These changes manifest as crampy abdominal pain, bloating, diarrhea (due to bowel distention), palpitations, and lightheadedness (due to intravascular volume contraction). [31, 32]  Episodes may be prevented by intake of smaller but more frequent meals with reduced sugar content. Exercise must be avoided soon after a meal. Octreotide is prescribed for medical management. The corrective surgical procedure is interposition of an iso/antiperistaltic jejunal loop or creation of a long-limb Roux-en-Y anastomosis.

Late dumping syndrome is observed 2-3 hours after a meal and causes milder and shorter-lasting symptoms than early dumping syndrome does. [31, 32]  It is attributed to the functional hyperinsulinism that occurs in response to the postprandial hyperglycemia caused by two factors: rapid gastric emptying due to gastrectomy and loss of parasympathetic innervation of the pancreas in cases with vagotomy. Symptoms are alleviated by administering glucose. [31, 32]  Along with preventive dietary measures, pectin or acarbose may be prescribed. For refractory symptoms, antiperistaltic jejunal loop interposition is one of the procedures performed.

Metabolic disturbances may include iron deficiency anemia and vitamin B12 deficiency anemia, impaired fat absorption (steatorrhea), and osteoporosis and osteomalacia due to calcium deficiency. The presence of vitamin D deficiency has been used as a predictor of the persistence of metabolic syndrome, especially in patients undergoing gastric bypass for morbid obesity. [33]

Colic is encountered more frequently in cases with vagotomy; it may accompany dumping or precede bilious vomiting or diarrhea.

Weight loss is possible because the patient enters a stage of negative nitrogen balance. The weight loss is usually proportional to the amount of stomach resected.

Asthenia is a poorly understood complication for which testosterone is used with some success in males.

Postgastrectomy syndromes secondary to gastric reconstruction

Postgastrectomy syndromes secondary to gastric reconstruction may include the following:

  • Afferent loop syndrome
  • Efferent loop syndrome
  • Retained antrum syndrome
  • Alkaline reflux gastritis
  • Roux-en-Y stasis syndrome

With afferent loop syndrome, the patient complains of nausea or colic within 10 minutes of a meal, followed by bilious vomiting, which relieves the former symptoms. [34]  This syndrome occurs due to complete or partial mechanical obstruction at the gastrojejunostomy or at a point along the jejunal portion of the afferent loop, leading to its distention with bile and other enteric secretions. Secondarily, prolonged stasis facilitates bacterial overgrowth, predisposing the patient to steatorrhea, malnutrition, and vitamin B12 deficiency. In medically unresponsive cases, conversion of the Billroth II to a Billroth I or Roux-en-Y anastomosis is done.

Efferent loop syndrome is a rare complication caused by herniation of the efferent limb behind the anastomosis in a right-to-left manner. It is managed operatively by reducing the hernia and obliterating the retroanastomotic hernial recess.

In some patients who have undergone a Billroth II procedure, retained antrum syndrome occurs if residual antrum is retained in the duodenal stump. This leads to hypergastrinemia due to repeated exposure of the retained antrum to alkaline intestinal content. [35]  This in turn leads to increased acid secretion, which may result in recurrent ulceration. It may be medically treated with H2-receptor blockers or proton pump inhibitors (PPIs). Medically unresponsive symptoms are alleviated by either excision of the residual antral mucosa or conversion of a Billroth II reconstruction to a Billroth I.

Alkaline reflux gastritis entails chronic gastritis and symptoms of nausea, bilious vomiting, and burning pain caused by reflux of alkaline intestinal contents. Patients with excessive reflux undergo Roux-en-Y revision to obtain symptomatic relief.

Roux-en-Y stasis syndrome is identified by a constellation of symptoms that includes vomiting of food but not bile, postprandial pain, and nausea. [36]  On endoscopy, the gastric remnant and Roux limb are dilated, but no evidence of mechanical obstruction can be identified on oral contrast study. The length of the Roux-Y limb is identified as the major risk factor for this condition. Conservative treatment with promotility agents can be attempted. If this fails, various surgical options are possible, including total gastrectomy if a significant gastric remnant is present or excision of the Roux limb and reconstruction as a Billroth II anastomosis with an enteroenterostomy between the afferent and efferent limbs.

The so-called candy cane syndrome is a poorly described delayed complication that causes abdominal pain, nausea, and vomiting after Roux-en-Y gastric bypass. The symptoms are due to a blind afferent loop of the gastrojejunostomy, which on endoscopy is visualized as the most direct outlet from the gastrojejunostomy. The problem can be treated safely by resecting the blind afferent limb.  Minimizing the size of the blind afferent loop can prevent the occurrence of this complication. [37]

Postvagotomy syndromes

In cases where gastrojejunostomy is accompanied by a vagotomy, complications may include the following:

  • Postvagotomy diarrhea
  • Chronic gastric atony
  • Incomplete vagal transection

Postvagotomy diarrhea usually resolves with time. If it persists, bile acid–binding resins can be administered. Surgical correction is rarely required. Reverse jejunal interposition of about 10 cm is required at 80-100 cm distal to the duodenojejunal flexure.

For chronic gastric atony, metoclopramide may be useful.

In a patient with peptic ulcer disease, incomplete vagal transaction can lead to recurrent ulceration. [38]  If this is not controlled by administration of PPIs or eradication of Helicobacter pylori eradication, surgical correction can be carried out by means of thoracic vagotomy or Billroth II gastrectomy.

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