Laparoscopic gastrojejunostomy

Laparoscopic Gastrojejunostomy Emma J. Patterson, MD, FRCSC, and Michel Gagner, MD, FRCSC, FACS

L

aparoscopic gastrojejunostomy (LGJ) was first described in case reports in 1992,1-5 and by 1995 several clinical series had been published. 6,7 This procedure is now relatively straightforward for surgeons who perform advanced laparoscopic procedures on a daily basis, but it has not yet been widely adopted by general surgeons.

Diagnosis Most patients with gastric outlet obstruction (GO0) secondary to ulcer disease have a long history of ulcer symptoms, and up to 30% have been treated for obstruction or perforation in the past. They may complain of gradually increasing epigastric pain, followed by anorexia, vomiting, and failure to gain relief from antacids. Vomitus often contains food ingested several hours earlier, and the absence of bile staining reflects the site of the blockage. Peristalsis of the distended stomach may be visible on gross inspection, and a succussion splash often can be elicited. Upper abdominal tenderness is a common finding on physical examination, and weight loss may be marked if the patient has delayed seeking medical attention.

Investigations Before surgical therapy for peptic ulcer disease, endoscopy is necessary to rule out malignant causes of obstruction such as duodenal or pancreatic cancer. These patients should also be tested for Helicobacter pylori with gastric antral biopsies. Patients with severe ulcer disease warranting operation should be screened for ZollingerEllison syndrome. Routine diagnostic imaging before LGJ should include an upper gastrointestinal contrast study and a computed tomography (CT) scan with oral and intravenous contrast. These studies will confirm the diagnosis of GOO and may detect obstructing lesions and metastatic disease. Endoscopic and laparoscopic ultrasound may be useful to image or biopsy any obstructing pathology.

From the Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY. Address reprint requests to Michel Gagner, MD, Chief, Division of Laparoscopic Surgery, Department of Surgery, Box 1103, 19 East 98th St, New York, NY 10029. Copyright 9 2000 by W.B. Saunders Company 1524-153X/0010204-0004510.00/0 doi:10.1053/otgn.2000.19140

Patient Selection The most common indications for LGJ are complicated peptic ulcer disease (PUD) and malignant obstruction secondary to periampullary cancer (Table 1). Cycles of inflammation and repair in duodenal or prepyloric gastric ulcers may cause obstruction of the gastroduodenal junction as a result of edema, muscular spasm, and scarring. The diagnostic challenge for the surgeon is to differentiate obstruction due to PUD from a malignant tumor of the antrum or pancreas. Malignancy is becoming the most common cause of gastric outlet obstruction, and it may be difficult to diagnose. The incidence of peptic ulcer disease is decreasing. Since the introduction of histamine2-receptor blockers, proton pump inhibitors, and H. pylori eradication therapy, surgical intervention for GOO due to ulcer disease has become uncommon. Acute GOO secondary to PUD will resolve with nonsurgical therapy (fluid and electrolyte repletion and nasogastric tube decompression for several days until the peripyloric edema and inflammation subsides) in one third of patients. Thus, about two thirds of patients with acute obstruction fail to improve sufficiently on medical therapy and require an operation to relieve the blockage. If five to seven days of gastric suction do not relieve the obstruction, the patient should be treated surgically. Other indications for surgical management include failure of the obstruction to resolve completely (eg, if the patient can take only liquids) and recurrent obstruction. The prophylactic palliation of GOO secondary to periampullary malignancies has long been controversial among surgeons. It has been standard practice that if the patient's life expectancy is at least six months, then a prophylactic GJ is performed. Recent clinical trials support the performance of GJ in patients found to be unresectable during a planned therapeutic pancreaticoduodenectomy. Lillemoe et als recently published a prospective randomized trial addressing this issue. Between 1994 and 1998, they explored 194 patients with periampullary malignancy for the purpose of pancreaticoduodenectomy who were found to have unresectable disease. On the basis of preoperative symptoms, radiologic studies, or surgical findings, 107 patients were determined to be at high risk for duodenal obstruction and had GJ performed. The remaining 87 patients were assessed to be at low risk for duodenal obstruction and were randomized to undergo either prophylactic GJ (44

Operative Techniques in General Surgery, Vol 2, No 4 (December), 2000: pp 319-326

319

320

Patterson and Gagner

Table 1. Causes of Gastric Outlet Obstruction and Indications for LGJ

Category Congenital Acquired Infectious Traumatic Toxic Neoplastic Benign Malignant Degenerative Inflammatory latrogenic

Vascular

Diagnosis

LGJ Indicated? (+/-)

Hypertrophic pyloric stenosis Annular pancreas Duodenal atresia Tuberculosis Duodenal mural hematoma Caustic ingestion Gastreduodenal polyps Periampullary cancers Amyloidosis Chronic peptic ulcer Acute pancreatitis Chronic pancreatitis Postoperative duodenal fistula Gastroduodenal mucosal intussusception (postgastrostomy) Hepatic compression after omphalocele closure Superior mesenteric artery syndrome

+ + + + + +

+

patients) or no GJ (43 patients). There was no difference in mean length of stay (8.5 v 8.0 days), morbidity (32% v 33%) or survival (8.3 months) between the two groups. During that time, GOO developed in none of the 44 patients who underwent GJ, and GOO requiring therapeutic intervention developed in eight of 43 patients (19%) who did not. The results of this trial demonstrate that prophylactic GJ significantly decreases the incidence of late GOO. Less common indications for LGJ include GOO due to chronic pancreatitis or Crohn's disease. Most patients with Crohn's disease can be treated nonsurgically, with surgical therapy advocated for those patients with complications that do not resolve with nonsurgical therapy. 9 Locally advanced or metastatic cancers originating almost anywhere in the abdomen or retroperitoneum can cause GOO, and the patient's overall condition and prognosis may warrant LGJ. An accurate preoperative pathologic diagnosis is important to avoid the potential pitfall of mistaking a malignancy for chronic PUD. However, most cancers that are large enough to obstruct the duodenum are not likely to be curable. It may be difficult to rule out malignancy with certainty in all cases of pyloric obstruction. The particular difficulty in this anatomic region is that surgical resection requires a major operation, pancreaticoduodenectomy.

Preoperative Preparation Preoperative preparation should include nasogastric drainage and fluid and electrolyte replacement. Prolonged vomiting leads to metabolic alkalosis with dehydration, hypochloremia, hypokalemia, and hyponatremia. Treat-

ment involves intravenous replacement of water and sodium chloride until satisfactory urine output has been established, followed by initiation of potassium chloride replacement. If chronic obstruction has produced severe malnutrition, then total parenteral nutrition may be instituted for two to three weeks preoperatively to reverse the patient's catabolic state. Serial measurements of serum prealbumin are done to monitor the patient's improved nutritional status. Patients considered for elective surgery should probably discontinue acid suppression medications for about 72 hours before the operation to restore gastric acidity and to minimize bacterial overgrowth. 1~ If H. pylori is present, it should be eradicated with appropriate therapy before surgery.

Operative Strategy If the indication for LGJ is PUD, concomitant vagectomy (truncal or selective) is performed to reduce gastric acid secretion. Obstruction secondary to other causes, such as carcinoma or Crohn's disease, does not warrant vagectomy. Traditionally, GJ is performed antecolic for carcinomatous obstruction, and retrocolic for benign indications. This is controversial, and there have been no controlled trials providing good evidence for one technique over the other. We prefer to use an antecolic approach in all circumstances, because it is technically easier and avoids potential vascular compromise of the transverse mesocoIon.

Equipment In addition to standard laparoscopic equipment and instruments, the following specific instruments should be available: 9 Split-leg table (Betastar 1131.02; Maquet Corp., Rastatt, Germany) 9 Two high-flow (20 L/min) insufflators (Karl Storz, Tuttlingen, Germany) 9 10-mm 30 ~ laparoscope (Storz) 9 Fan liver retractor (Storz) 9 Dorsey atraumatic bowel graspers (Storz) 9 Maryland and right-angled dissectors (Storz) 9 Ultrasonic coagulating shears (Ultracision; US Surgical Corp, Norwalk, CT) 9 Laparoscopic linear cutting stapler (EndoGIA II, 45 m m • 3.5 m m staples; US Surgical Corp) 9 Multi-fire laparoscopic clip applier (Ligaclip; US Surgical Corp) 9 Laparoscopic needle drivers 9 2-0 silk suture on a ski-tip needle Although LGJ is not technically difficult compared to other advanced laparoscopic procedures, it does require advanced skills such as endoscopic stapling, bowel handling, and intracorporeal suturing and knot-tying techniques.

Laparoscopic Gastrojejunostomy

321

SURGICAL TECHNIQUE

1 Laparoscopic surgery of the foregut is ideally performed with the surgeon standing between the patient's abducted legs, with the patient either in the modified lithotomy position or on a split-leg table. Our personal preference is the Betastar split-leg table, which has leg boards that split and distract to create a space for the surgeon to stand between the legs without putting any pressure on the patient's joints or neurovascular structures. The scrub nurse stands to the surgeon's right, and the first assistant stands to the left and operates the camera and liver retractor. An orogastric tube is inserted by the anesthesiologist, intermittent calf compression devices are placed for deep venous thrombosis prophylaxis, and an intravenous antibiotic is administered.

2 Trocar positions for LGJ. The 10-mm port is first placed at the umbilicus using the open technique. The 30 ~ scope is inserted, and the remaining trocars are inserted under direct vision. The 12-mm port for the stapler is placed as far to the patient's right as possible to facilitate performance of the stapled gastrojejunal anastomosis. Two five-millimeter working ports are placed, one on either side of the umbilicus. In general, all trocars should be at least five centimeters apart to prevent "swordfighting" between instruments.

//

9 10 12

,(~, ;

I0"

As~

; )

\

322

Patterson and Gagner

3 The left lobe of the liver is retracted anteriorly using a blunt 10-ram fan retractor, with the fingers of the retractor kept closed. (The instrument is less traumatic in this position compared to when the fingers are fanned out.) The lesser sac is exposed via a window made in the gastrocolic ligament using the ultrasonic coagulating shears. The gastroepiploic vessels are preserved. The posterior gastric wall is then visualized, and a suitable site is located for the side-to-side gastrojejunal anastomosis.

4 Atraumatic bowel graspers are used to run the small bowel and identify the ligament of Treitz. Positioning the patient in reverse Trendelenburg position with the left side up facilitates this maneuver. The 10-mm fan retractor is used to "row" the transverse colon and omentum superiorly toward the patient's head. The ligament of Treitz can then be identified by following the highest, most medially located loop of small bowel proximally.

kaparoscopic Gastrojejunostomy

323

5 After the ligament of Treitz_ is identified, the jejunum is measured 50 cm distally, and this loop is brought up antecolic and isoperistahic to lie alongside the posterior gastric wall. Some surgeons find it useful to loosely approximate the stomach and jejunum with one or two interrupted "stay sutures" that facilitate formation of the stapled anastomosis. In experienced hands, such sutures are often unnecessary.

~y~acfMou_~

6 A gastrotomy is made using the harmonic scalpel. The wall of the obstructed stomach can be very thick (up to one centimeter). The instrument used to make the gastrotomy must be aimed exactly perpendicular to the stomach wall to avoid raising a flap of stomach wall. An enterotomy is made on the antimesenteric side of the jejunum, directly opposite the gastrotomy.

324

Patterson and Gagner

. J " "> L "

7~ \

f

,

i<

,

"X

A

7 (A) The EndoGIA stapler is inserted and fired from the right-sided 12-mm lateral port. In preparation for stapling, the anesthesiologist removes all tubes from the esophagus (orogastric tube and esophageal stethoscope). The large side of the stapler is inserted into the gastrotomy, and the small side is inserted into the enterotomy. The stomach and jejunum are then carefully advanced onto the stapler by pulling with atraumatic bowel graspers. The stapler should not be forced into the bowel, because inadvertant enterotomies can easily occur on the back wall of the bowel. (B) Once the stapler is in good position for anastomosis, it is closed and fired. The stomach and bowel are held with the graspers while the stapler is closed and fired; otherwise, it may slip, and the resulting anastomosis will be short. The stapler is opened and carefully removed, closing it as it is withdrawn from the lumen of the anastomosis. It is important that the gastroenterostomy not be dilated with the stapler as the stapler is removed, to minimize the size of the enterotomy that must be sutured closed. To lengthen the anastomosis to approximately seven centimeters, we use either three 45-ram or two 60-mm stapler cartridges. The anastomosis is carefully inspected for hemostasis. A close-up view of the mucosal side of the staple line is obtained, and small arterial bleeding points are controlled using clips, sutures, and/or ultrasonic coagulating shears.

Laparoscopic Gastrojejunostomy

325

8 (A) The common enterotomy is closed intracorporeally with sutures of the surgeon's choice. In laparoscopic suturing, the sutures are generally one size larger than those used in open surgery. We prefer 2-0 silk with a ski-tip needle. The first suture is run from the patient's left side toward the middle of the opening. (B) A second suture is started from the opposite end to complete the closure, and the sutures are tied together in the middle.

9 A methylene blue test is performed to check for anastomotic leaks. An orogastric tube is placed by the anesthesiologist so that the tip of the tube lies near the anastomosis. The efferent limb of the jejunum is clamped with a 10-mm atraumatic bowel clamp about five centimeters distal to the anastomosis. Methylene blue (one vial diluted in 500 mL of normal saline) is then slowly infused into the tube. The abdomen is then inspected for hemostasis, and a closed suction drain is placed in the lesser sac, posterior to the anastomosis. All trocar sites larger than five millimeters are closed using a suture passer. Creation of a feeding jejunostomy is optional.

326

Postoperative C a r e Nasogastric tubes are not used postoperatively. A watersoluble upper gastrointestinal contrast study is obtained the morning after surgery. This will detect the most significant complications, anastomotic leaks or obstruction from too small an opening. The triple-stapled technique of closing the common enterotomy with a stapler tends to narrow one limb of the anastomosis, and for this reason we avoid this technique. If the study is normal, then the patient is started on a clear liquid diet. If fluids are tolerated, then oral analgesics are begun on postoperative day two. Early ambulation is encouraged, and following the passage of flatus, the diet is advanced to soft solids and the patient is dismissed.

Results Several series have shown that GJ can be safely performed to relieve GOO from. either benign or malignant disease or to provide prophylaxis against it in the case of unresectable malignant disease. Small series involving four to 16 patients report that LGJ is at least equal to open surgery in terms of return of gastrointestinal function and length of hospital stay (mean stays of four to 10 days). 6,TA1A2 The transition from open to laparoscopic technique has brought no detectable increase in complications. One case-controlled study compared open GJ to LGJ for palliation of advanced pancreatic cancer. 13 Hospital stay was significantly reduced in LGJ patients (10 days versus 15 days for open GJ). Over the past five years, 21 patients have undergone laparoscopic gastrojejunostomy at our institution, 14 nine for malignancy, six for GOO related to PUD, and five for Crohn's disease, and one other. The mean operative time was 142 minutes __+ 60 (SD). The median time to the initiation of clear liquid diet was one day, and the median postoperative length of hospital stay was 4.7 days (range, two to 102 days). The length of stay was significantly

Patterson and Gagner

longer for those patients with cancer (mean, 22.4 days) than those with benign disease (mean, 4.9 days) (P = .02). Of the 21 patients, two experienced complications that required reoperation: one had efferent loop obstruction, and one had efferent loop intussusception.

REFERENCES 1. Mouiel J, Katkhouda N, White S, et al: Endolaparoscopic palliation of pancreatic cancer. Surg Laparosc Endosc 2:241-243, 1992 2. Nathanson LK: Laparoscopic cholecyst-jejunostomy and gastroenterostomy for malignant disease. Surg Oncol 2 (suppl 1):19-24, 1993 3. Wilson RG, VarmaJS: Laparoscopic gastroenterostomy for malignant duodenal obstruction. BrJ Surg 79:1348, 1992 4. Rangraj MS, Mehta M, Zale G, et al: Laparoscopic gastrojejunostomy: A case presentation. J Laparoendosc Surg 4:81-87, 1994 5. Sosa JL, Zalewski M, Puente I: Laparoscopic gastrojejunostomy technique: case report. J Laparoendosc Surg 4:215-220, 1994 6. Nagy A, Brosseuk D, Hemming A, et al: Laparoscopic gastroenterostomy for duodenal obstruction. AmJ Surg 169:539-542, 1995 7. Rhodes M, Nathanson L, Fielding G: Laparoscopic biliary and gastric bypass: A useful adjunct in the treatment of carcinoma of the pancreas. Gut 36:778-780, 1995 8. Lillemoe KD, Cameron JL, Hardacre JM, et al: Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 230:322-328, 1999 9. Fitzgibbons TJ, Green G, Silberman H, et al: Management of Crohn's disease involving the duodenum, including duodenal cutaneous fistula. Arch Surg 115:1022-1028, 1980 10. Kauffman GL, Conter RL, Greenfield LJ, et al: Surgery: Scientific principles and practice (ed 2). Philadelphia, PA, LippincottRaven, 1997 11. Brune IB, Feussner H, Neuhaus H, et al: Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis. Surg Endosc 11:834-837, 1997 12. Casaccia M, Diviacco P, Molinello P, et al: Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: Reflections on the preliminary results. Surg Laparosc Endosc 8:331-334, 1998 13. Bergamaschi R, Marvik R, Thoresen JE, et al: Open versus laparoscopic gastrojejunostomy for palliation in advanced pancreatic cancer. Surg Laparosc Endosc 8:92-96, 1998 14. Kurian M, Patterson E, Vine A, et al: Laparoscopic gastrojejunostomy: Safety and efficacy. Surg Endosc 2000