Overview
Definition:
Jejunogastrostomy for an obstructed gastric conduit is a surgical procedure to re-establish gastrointestinal continuity when a previously created gastric conduit, typically used for esophageal replacement, becomes functionally obstructed.
Epidemiology:
Obstruction of gastric conduits can occur in 5-15% of patients following esophagectomy, with causes including anastomotic strictures, internal hernias, adhesions, or conduit ischemia
Jejunal interposition conduits have a lower incidence of obstruction.
Clinical Significance:
This condition significantly impacts a patient's quality of life, leading to dysphagia, malnutrition, and dehydration
Prompt diagnosis and management are crucial to prevent severe morbidity and mortality, and understanding this complication is vital for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Progressive dysphagia, initially to solids then liquids
Odynophagia
Regurgitation of undigested food
Weight loss and malnutrition
Dehydration
Epigastric pain
Heartburn
Occasional vomiting.
Signs:
Cachectic appearance
Signs of dehydration (poor skin turgor, dry mucous membranes)
Epigastric tenderness
Distended abdomen in cases of complete obstruction
Absent bowel sounds in rare, severe cases.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion in a patient with a history of gastric conduit reconstruction, confirmed by imaging and endoscopic evaluation
Absence of passage of contrast or food distal to the obstruction.
Diagnostic Approach
History Taking:
Detailed history of the primary esophageal pathology and reconstructive surgery
Timeline of symptom onset and progression
Previous interventions or complications
Nutritional status and weight loss history
Red flags include rapid weight loss, inability to tolerate any oral intake, and signs of ischemia.
Physical Examination:
General assessment for nutritional status and hydration
Abdominal examination for tenderness, distension, palpable masses, and bowel sounds
Examination of the neck and chest for signs of infection or fistulas.
Investigations:
Barium swallow with gastrografin: Crucial for visualizing the conduit, identifying the site and nature of obstruction (stricture, extrinsic compression, intraluminal mass)
Esophagogastroduodenoscopy (EGD): Allows direct visualization of the conduit lumen, assessment of the mucosa, biopsy of suspicious lesions, and potential therapeutic interventions like balloon dilation
CT scan: Useful for evaluating extraluminal causes of obstruction such as adhesions, internal hernias, or lymphadenopathy
Upper GI series with contrast is typically the initial investigation of choice.
Differential Diagnosis:
Anastomotic stricture (most common)
Conduit ischemia or necrosis
External compression from enlarged lymph nodes or tumor recurrence
Internal hernia through a mesenteric defect
Conduit twisting or kinking
Benign or malignant strictures within the conduit itself
Gastric outlet obstruction if the conduit is too small.
Management
Initial Management:
Bowel rest and nasogastric (NG) tube decompression if vomiting is present
Aggressive intravenous fluid resuscitation to correct dehydration and electrolyte imbalances
Nutritional support via parenteral nutrition (TPN) or jejunal feeding if possible proximal to the obstruction
Pain management.
Medical Management:
Proton pump inhibitors (PPIs) to reduce gastric acid secretion and aid mucosal healing
Prokinetics may be considered in select cases if motility is suspected, though less effective for mechanical obstruction
Antibiotics for any signs of infection or aspiration pneumonia.
Surgical Management:
Surgical intervention is indicated for severe or persistent obstruction, conduit ischemia, or when conservative measures fail
Options include: Revision of the conduit, freeing adhesions, or performing a stricturoplasty
Conversion to an alternative reconstructive method (e.g., colon interposition or jejunal interposition) if the gastric conduit is unsalvageable
Creation of a distal feeding jejunostomy if reconstruction is not feasible or to ensure adequate nutrition
In cases of conduit ischemia, resection and diversion may be necessary.
Supportive Care:
Close monitoring of fluid balance, electrolytes, and nutritional status
Regular vital sign monitoring
Early mobilization to prevent venous thromboembolism
Psychological support for the patient regarding their altered eating capacity and prognosis.
Complications
Early Complications:
Leak from the anastomosis
Conduit ischemia or necrosis
Hemorrhage
Sepsis
Pneumonia
Anastomotic leak.
Late Complications:
Stricture formation at the anastomosis or within the conduit
Marginal ulcers in the stomach remnant
Gastric conduit dysmotility
Internal hernias
Adhesions causing bowel obstruction
Strictures can occur weeks to years post-op.
Prevention Strategies:
Meticulous surgical technique during conduit creation, ensuring adequate blood supply and appropriate tension
Careful handling of tissues
Secure and tension-free anastomoses
Early diagnosis and management of anastomotic leaks
Prophylactic use of PPIs
Avoidance of unnecessary abdominal surgeries post-reconstruction.
Prognosis
Factors Affecting Prognosis:
The underlying reason for obstruction (ischemia vs
stricture)
Patient's nutritional status
Presence of comorbidities
Success of definitive surgical intervention
Development of major complications like sepsis or complete conduit loss.
Outcomes:
With timely and appropriate management, patients can achieve significant improvement in swallowing function and nutritional status
Outcomes are generally good for benign strictures managed with dilation or revision
However, conduit loss due to ischemia carries a poorer prognosis, often requiring re-operation with alternative reconstructive methods.
Follow Up:
Regular follow-up is essential, including clinical assessment of swallowing and nutritional status, and periodic endoscopic surveillance, especially for patients with benign strictures or those at risk of recurrence
Imaging studies may be required to monitor for complications like strictures or hernias.
Key Points
Exam Focus:
Recognize the symptoms of gastric conduit obstruction
Differentiate between benign strictures and ischemia
Understand the role of barium swallow and EGD in diagnosis
Know the surgical options for management, including revision, conversion, or diversion
Importance of nutritional support.
Clinical Pearls:
A high index of suspicion is key in patients with a history of esophageal reconstruction presenting with dysphagia
Always consider conduit ischemia as a critical, emergent cause
Multidisciplinary team approach is often required for optimal management.
Common Mistakes:
Delayed diagnosis leading to malnutrition and dehydration
Misinterpreting imaging findings
Aggressively dilating a potentially ischemic conduit
Inadequate nutritional support during the diagnostic and management phase
Not considering extraluminal causes of obstruction.