Overview
Definition:
Gastrojejunostomy is a surgical procedure that creates an anastomosis between the stomach and the jejunum, bypassing the duodenum
It is primarily performed to relieve gastric outlet obstruction (GOO), a condition where the passage of food from the stomach to the small intestine is severely impaired.
Epidemiology:
Gastric outlet obstruction can be caused by various conditions, including peptic ulcer disease (most common in developed countries, historically), gastric malignancies, post-operative strictures, and inflammatory conditions like Crohn's disease
Incidence varies geographically and with the prevalence of specific etiologies.
Clinical Significance:
Effective relief of GOO is crucial for restoring nutritional status, alleviating debilitating symptoms like vomiting and abdominal pain, and improving the patient's quality of life
Gastrojejunostomy serves as a definitive surgical solution for unresectable GOO or as a palliative measure in malignant cases.
Indications
Absolute Indications:
Unrelenting symptoms of gastric outlet obstruction due to benign or malignant causes where definitive gastric resection is not feasible or indicated
Common etiologies include distal gastric cancer, peri-ampullary tumors causing duodenal compression, severe pyloric stenosis from chronic peptic ulcer disease, or post-surgical strictures.
Relative Indications:
Symptomatic GOO in patients with poor surgical risk where a less extensive procedure is preferred
Palliative relief of symptoms in advanced malignancy, aiming to improve oral intake and reduce hospitalizations.
Contraindications:
Active upper GI bleeding not amenable to endoscopic control, severe coagulopathy, uncontrolled sepsis, extensive intra-abdominal carcinomatosis making anastomotic leakage a high risk, or patient's inability to tolerate major surgery.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on duration and severity of symptoms, nutritional status, and comorbidities
Assessment for dehydration and electrolyte imbalances is critical.
Resuscitation:
Aggressive intravenous fluid resuscitation to correct dehydration and electrolyte disturbances, particularly hypochloremic alkalosis due to persistent vomiting
Nasogastric tube insertion for gastric decompression to relieve distension and reduce vomiting.
Nutritional Support:
Parenteral nutrition or jejunal feeding may be initiated if the patient is severely malnourished or if surgery is delayed
Optimization of nutritional status improves surgical outcomes.
Investigations:
Complete blood count (CBC), electrolytes, renal function tests (RUVL), liver function tests (LFTs), coagulation profile
Upper GI endoscopy to confirm obstruction, assess etiology, and rule out bleeding or malignancy
Cross-sectional imaging (CT scan) of the abdomen to assess the extent of disease, resectability, and presence of metastases.
Procedure Steps
Surgical Approaches:
Can be performed via open laparotomy or laparoscopy
Laparoscopic gastrojejunostomy offers potential benefits like reduced pain, shorter hospital stay, and faster recovery.
Anastomotic Technique:
Typically, a Billroth II (polya) type anastomosis or a Roux-en-Y gastrojejunostomy is created
The chosen technique depends on surgeon preference, the underlying pathology, and the need to isolate the anastomosis from the biliary/pancreatic outflow in cases of malignancy
A side-to-side or antecolic, antegastric anastomosis is commonly performed.
Gastric Preparation:
The stomach is dissected free from adhesions and the gastrocolic omentum is divided to mobilize the anterior gastric wall
A suitable site for anastomosis is selected distal to the obstruction and proximal to the pylorus.
Jejunal Mobilization:
The proximal jejunum is mobilized
For a Billroth II, the efferent limb is brought up
For Roux-en-Y, a loop of jejunum is transected, and the proximal end is anastomosed to the stomach, while the distal end is anastomosed to the jejunum distally to restore intestinal continuity.
Anastomosis Creation:
The anastomosis is created using sutures or surgical staplers, ensuring adequate luminal size to prevent future stenosis
Hemostasis is meticulously achieved throughout the procedure.
Postoperative Care
Gastric Decompression:
A nasogastric tube is usually left in place postoperatively for continuous gastric decompression
It is typically clamped for trial feedings and removed when bowel sounds return and drainage is minimal.
Fluid Management:
Intravenous fluids are continued, with careful monitoring of electrolytes and fluid balance
Gradual advancement of diet is initiated as tolerated, starting with clear liquids and progressing to a soft diet.
Pain Management:
Adequate analgesia is provided, often with patient-controlled analgesia (PCA) initially, followed by oral pain medications.
Monitoring:
Close monitoring for signs of complications such as anastomotic leak, intra-abdominal abscess, ileus, or bleeding
Vital signs, abdominal examination, and laboratory parameters are regularly assessed.
Complications
Early Complications:
Anastomotic leak, intra-abdominal abscess, postoperative ileus, bleeding from the anastomosis or staple lines, gastric distension, and wound infection
Early dumping syndrome may also occur.
Late Complications:
Marginal ulceration at the gastrojejunal anastomosis, afferent loop syndrome (obstruction of the afferent limb), anastomotic stricture formation, malnutrition due to malabsorption or inadequate oral intake, and weight loss
Late dumping syndrome can also be problematic.
Prevention Strategies:
Meticulous surgical technique, adequate gastric decompression, careful fluid and electrolyte management, early mobilization, and appropriate dietary progression are key
Prophylactic proton pump inhibitors (PPIs) may be used to reduce the risk of marginal ulceration.
Prognosis
Factors Affecting Prognosis:
The prognosis is largely dependent on the underlying cause of obstruction, the stage of the disease (especially in malignant cases), the patient's overall health status, and the successful management of complications
Early and accurate diagnosis and intervention lead to better outcomes.
Outcomes:
For benign causes, gastrojejunostomy can provide long-term relief and restore adequate oral intake and nutritional status
In malignant cases, it offers palliative relief, improving quality of life and enabling some level of oral feeding, though survival is limited by the underlying cancer.
Follow Up:
Regular follow-up is essential to monitor for signs of complications, assess nutritional status, and manage any emerging issues
In malignant cases, follow-up will also involve oncological staging and treatment.
Key Points
Exam Focus:
DNB and NEET SS exams often test indications for gastrojejunostomy, comparison with other palliative procedures (e.g., feeding jejunostomy, stenting), types of anastomosis (Billroth II vs
Roux-en-Y), and management of early/late complications
Understanding the pathophysiology of GOO and its impact on nutrition is vital.
Clinical Pearls:
Always consider nutritional status and potential for malnutrition in patients with GOO
Gastric decompression with an NG tube is a critical initial step
Laparoscopic approach can be beneficial but requires significant surgical expertise
Thorough exploration for resectability is paramount in suspected malignancy.
Common Mistakes:
Inadequate gastric decompression preoperatively
Failure to adequately correct electrolyte imbalances
Creating too small an anastomosis, leading to obstruction
Misjudging resectability in malignant cases, leading to inappropriate palliative stenting when resection might have been possible.