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Open gastrojejunostomy
Open Gastrojejunostomy Christopher J. Sonnenday, MD, and Charles J. Yeo, MD
hile the volume of gastric surgery performed in surgical training programs in the United States has decreased markedly in recent years with the virtual disappearance of elective ulcer operations,1 open gastrojejunostomy remains an important tool in the armamentarium of any general surgeon. Gastrojejunostomy is often performed to restore gastro-enteric continuity after resection or palliative bypass of malignant disease (gastric or periampullary), or as part of a gastric bypass procedure for morbid obesity. Further, gastrojejunostomy serves as a treatment option for benign obstruction to the gastric outlet or duodenum. This chapter will concentrate on the role of open gastrojejunostomy in the management of patients with benign disease.
W
INDICATIONS Open gastrojejunostomy may be indicated for any condition that functionally or mechanically impairs normal gastric emptying. Historically, the most common cause of gastric outlet obstruction requiring operative treatment has been peptic ulcer disease. Despite the recognition of Helicobacter pylori as a causative agent in peptic ulcer disease and the establishment of effective medical therapies, gastric outlet obstruction may occur in 6% to 8% of patients with chronic duodenal ulcer.2 Many of these patients may be managed initially with nonoperative therapy consisting of nasogastric suction, gastric acid inhibition, eradication of H. pylori, endoscopic dilation, and total parenteral nutrition. Those patients that fail nonoperative intervention require surgical therapy for persistent or recurrent obstruction.3,4 Endoscopic balloon dilation coupled with aggressive H. pylori therapy and high dose proton pump inhibition has been proposed as an alternative to surgical therapy, but recent trials report a symptomatic recurrence rate as high as 50%,5,6 with those patients experiencing a recurrence typically requiring surgical intervention. Gastrojejunostomy, accompanied by highly selective
From the The Johns Hopkins Medical Institutions, Baltimore,MD. *Note: All illustrations have been modified from Atlas of Surgery -Volume 2. Editor John L. Cameron; Illustrator Corinne Sandone; Mosby; St. Louis, 1994. Address reprint requests to Dr. Charles J. Yeo, Professor of Surgery and Oncology, The Johns Hopkins Hospital, Department of Surgery, Blalock 606, 600 N. Wolfe Street, Baltimore, MD 21287-4606. © 2003 Elsevier Inc. All rights reserved. 1524-153X/03/0502-0029$30.00/0 doi:10.1053/otgn.2003.35367
vagotomy (HSV), has been advocated as the primary nonresectional treatment of obstructing duodenal ulcer, because it appears to be a more effective gastric drainage procedure than pyloroplasty and carries a lower risk of perioperative morbidity and mortality than antrectomy.2,7 Csendes and colleagues2 compared gastrojejunostomy plus HSV, gastroduodenostomy plus HSV, or antrectomy plus HSV in a prospective trial and found both the gastrojejunostomy and antrectomy groups to have excellent and equivalent long-term outcomes. It is important to emphasize that gastrojejunostomy alone is not believed to be an adequate therapy for obstructing peptic ulcer disease and should be accompanied by vagotomy to prevent marginal ulceration at the gastrojejunal anastomosis. Chronic pancreatitis is another important cause of gastric outlet obstruction. While acute pancreatitis is often associated with transient gastroduodenal dysmotility, these patients rarely require operative intervention. While less than 1% of all patients with chronic pancreatitis will develop fixed duodenal stenosis, up to 25% of patients with complicated chronic pancreatitis will require surgery.8,9 Thorough evaluation of these patients is necessary to rule out other associated conditions which would mandate different therapy, such as peptic ulcer disease, pancreatic pseudocyst, or pancreatic ductal adenocarcinoma. Gastroduodenal obstruction secondary to duodenal stricture may occur in 1% to 3% of patients with Crohn’s disease.10 Approximately one-third of these patients may eventually need surgical treatment, and gastrojejunostomy rather than duodenoplasty is the procedure of choice in these patients.11 Again, vagotomy is recommended at the time of this procedure to reduce the incidence of marginal ulceration.10 Other rare causes of mechanical gastroduodenal obstruction that may be treated effectively with gastrojejunostomy include congenital duodenal obstruction (due to atresia, webs, or duplication), annular pancreas, and posttraumatic strictures of the pylorus or duodenum. Patients with severe functional impairment to gastric emptying, in the absence of a mechanical obstruction, present a tremendous challenge in management. Systemic disorders such as diabetes mellitus, various collagen-vascular diseases, and autonomic neuropathies may be associated with severe gastroparesis. Idiopathic gastric atony has also been reported.12 Patients with functional gastric
Operative Techniques in General Surgery, Vol 5, No 2 (June), 2003: pp 73–79
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outlet obstruction may be referred to surgeons after failed trials of the prokinetic agents. In some instances, attempts at gastric pacing may have been attempted and failed.13 Although no large series or prospective trials exist for this small group of patients, gastrojejunostomy has been reported to provide benefit but only in highly selected patients.12,14,15 However, partial or complete gastric resection may eventually be necessary in some patients. Patients with gastroparesis are at extremely high risk of persistent gastric emptying problems after primary drainage procedures (pyloroplasty, gastrojejunostomy, and even antrectomy), and therefore procedures such as truncal vagotomy (which may worsen gastric motility) should be avoided.16
PREOPERATIVE EVALUATION The goals of the preoperative evaluation for a patient with gastroduodenal obstruction are: (1) appropriate resuscitation; (2) nutritional supplementation; and (3) to definitively exclude causes of obstruction that would require other medical or surgical therapy, particularly malignancy. Patients with chronic gastroduodenal obstruction can present with impressive dehydration and malnutrition due to protracted decreased oral intake and vomiting. Electrolyte and acid-base disturbances, classically a contraction hypochloremic metabolic alkalosis with hypokalemia, should be promptly identified and corrected. Nasogastric decompression may cease the vomiting and allow relief of gastric distention. Total parenteral nutrition is often necessary to begin the correction of proteincalorie malnutrition. Operative intervention is usually delayed until adequate hydration and electrolyte correction are achieved and until nutritional repletion is begun. The diagnosis of gastroduodenal obstruction is often suspected based on the findings at history and physical examination, and it may be further supported by the appearance of a large gastric air bubble on plain radiography of the abdomen. Confirmatory tests such as an upper gastrointestinal (GI) series or computed tomography (CT) with oral contrast may further support the diagnosis and isolate the location of the obstruction. In patients without a clear mechanical obstruction, scintigraphic imaging using both solid and liquid phases (dual phase nuclear medicine gastric emptying scan) may document an abnormality in gastric emptying. Before proceeding to the operating room for surgical therapy, it is usually essential that the mucosa of the stomach and duodenum be examined endoscopically in an effort to define the cause (and possibly the site) of the obstruction. Any thickened, inflamed, or ulcerated regions of the mucosa should be sampled, with the goal being to assess for malignancy, Crohn’s disease and H. pylori status. Other imaging studies such as CT, magnetic resonance, and endoscopic ultrasonography may be help-
ful in defining the underlying cause of the gastroduodenal obstruction.
TECHNICAL CONSIDERATIONS Antecolic Gastrojejunostomy. Open antecolic gastrojejunostomy is typically performed via an upper midline incision. If a nasogastric tube was not placed preoperatively, then such a tube is placed either immediately before or after the induction of general anesthesia to decompress the stomach. As always, careful inspection of the abdominal contents is performed, paying particular attention to the stomach, duodenum, and upper abdomen for any pathology not suspected in the preoperative evaluation. Any suspicious masses should be sent for frozen section analysis. The dependent portion of the greater curvature of the stomach is identified and cleared of the gastrocolic omentum. Typically the gastroepiploic arcade is divided along the gastric greater curvature (Fig 1). Some surgeons prefer to create the anastomosis equidistantly between the lesser and greater curvatures of the stomach, thereby avoiding the need to ligate any vessels along the greater curvature. The transverse colon with its attached greater omentum is then retracted cephalad, and the ligament of Treitz and proximal jejunum are identified (Fig 2). A gentle loop of proximal jejunum is brought up in an antecolic fashion without any associated tension and approximated to the greater curvature of the stomach where the greater curvature has been exposed. It is appropriate to create a relatively short afferent loop, however, it is important not to make the length of the afferent loop so short that it compresses the transverse colon. Our preferred technique of gastrojejunal anastomosis is performed by initially placing a posterior outer layer of 3– 0 silk seromuscular sutures (Fig 3). The gastrojejunal anastomosis is usually made 3 to 4 cm in length. Linear openings are then created within the stomach (as depicted in Fig 3) and subsequently in the jejunum adjacent to the posterior outer layer of 3– 0 silk sutures. Next, the inner layer of the posterior row is performed using a continuous locking suture of 3– 0 absorbable synthetic material (Fig 4). This suture is then brought anterior as the inner layer of the anterior row using a Connell technique. After the inner layer of the anterior row is completed, an outer layer of the anterior row is placed using interrupted 3– 0 silk seromuscular sutures. The final configuration of a typical antecolic gastrojejunostomy is shown in Fig 5. There are many alternative suturing techniques for performing a gastrojejunostomy. Additionally, stapling devices such as a linear stapler or a circular stapler can be used. In a considerable proportion of patients, an antecolic gastrojejunostomy does not appear to empty nearly as effectively as a retrocolic gastrojejunostomy. For this reason, our preference is to perform a retrocolic gastrojejunostomy in most patients who require open gastrojejunostomy.
1
The abdomen is entered through an upper midline incision and thoroughly explored. If an antecolic gastrojejunostomy is to be performed, then the most dependent portion of the gastric greater curvature is identified and cleared of omentum over a distance of 6 to 8 cm. The gastroepiploic arcade is typically left intact, caudal to the opening in the gastrocolic omentum.
2
The transverse colon is elevated with its omentum attached, and the ligament of Treitz and proximal jejunum are identified. A mobile loop of proximal jejunum is then brought up in an antecolic fashion, insuring that the afferent limb of the gastrojejunostomy does not compress the transverse colon.
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3
After approximating the gastric greater curvature and the mobile loop of proximal jejunum, the anastomosis is commenced. The anastomosis is performed by initially placing a posterior outer layer of 3– 0 silk Lembert sutures between the stomach and the jejunum. After insuring that the stomach has been decompressed via a nasogastric tube, a linear 3 to 4 cm gastrotomy is created. A parallel opening is then made in the jejunum, adjacent to the anterior gastrotomy.
4
The afferent and efferent limbs of jejunum are controlled with noncrushing clamps. The inner layer of the posterior row of the gastrojejunal anastomosis is placed using a continuous locking suture of 3– 0 synthetic absorbable material. This suture is continued anteriorly as the inner layer of the anterior row using a Connell stitch. The inner layer of the anterior row is then completed, and the noncrushing intestinal clamps are removed.
Retrocolic Gastrojejunostomy. After initial abdominal exploration, the most dependent portion of the greater curvature of the stomach is cleared of omentum, as was shown in the initial step of an antecolic gastrojejunostomy (Fig 1). An opening is then made bluntly in the transverse mesocolon, avoiding the mesocolic vessels (which run vertically), and typically a bit to the left of the midline and to the left of the middle colic vessels. A proximal loop of jejunum is brought through this rent in the transverse mesocolon (Fig 6), and the anastomosis is performed above the mesocolon in a fashion similar to that of an antecolic gastrojejunostomy (Fig 7). The completed anastomosis, which lies above the transverse mesocolon should not be left in this position. The gastrojejunostomy is then pulled down through the transverse mesocolon, and the transverse mesocolon is tacked to the stomach, circumferentially, at least 1 cm above the gastrojejunal anastomosis (Fig 8), thereby fixing the jejunal loop below the mesocolon. This will prevent an obstruction of the jejunum by the mesocolon.
POSTOPERATIVE CARE The primary principles of management of patients after gastrojejunostomy are: (1) ensuring continued adequate nutrition and hydration; (2) slow resumption of oral intake; and (3) anticipation of possible complications in-
5
The outer layer of the anterior row is completed using 3– 0 silk Lembert sutures. The final anatomy of an antecolic gastrojejunal anastomosis is shown here. There are no mesenteric defects to close, and no rents in the gastrocolic omentum or transverse mesocolon to repair.
6
The performance of a retrocolic gastrojejunostomy commences with similar maneuvers as for the antecolic gastrojejunal anastomosis. As shown in Fig 1, the greater omentum is cleared from the most dependent portion of the gastric greater curvature for a distance of 6 to 8 cm. Next, an opening is then made in the transverse mesocolon, usually to the left of the middle colic vessels, avoiding injury to major vessels within the mesocolon. A proximal loop of jejunum is brought through the transverse mesocolon, and the gastrojejunal anastomosis is performed above the transverse mesocolon, with the stomach and the jejunum approximated side-by-side. Note that for a retrocolic gastrojejunostomy, the length of the afferent limb can be shorter than for an antecolic gastrojejunostomy.
7
The completed retrocolic gastrojejunal anastomosis using an outer layer of interrupted 3– 0 silk Lembert sutures and an inner layer of running 3– 0 synthetic absorbable suture. It is important that the anastomosis not be left in this supramesocolic position, as the narrow opening in the transverse mesocolon can serve as an obstruction to the afferent and efferent jejunal limbs.
78
8
The gastrojejunal anastomosis is pulled down through the transverse mesocolon, and the transverse mesocolon is tacked to the stomach approximately 1 cm cephalad to the gastrojejunal anastomosis. Using this maneuver, the most dependent portion of the gastric greater curvature remains dependent, and the afferent and efferent limbs of the gastrojejunostomy reside entirely beneath the transverse mesocolon without the risk of obstruction by the mesocolon itself.
cluding delayed gastric emptying and marginal ulcer formation. Fluid and electrolyte replacement are standard, with attention to any preoperative deficits that may require further supplementation. Parenteral or enteral nutrition initiated in the preoperative period should be continued into the postoperative period until adequate oral intake can be established. Typically, we remove the nasogastric tube on the morning of the first postoperative day, as long as the output has not been excessive (greater than 500 to 1000 mL per 24 hours) and as long as the gastric pH is neutral (ie, acid secretion is suppressed pharmacologically). One exception to this practice of early nasogastric tube removal is the patient with a chronically dilated stomach that might be anticipated to be slow to regain motility, where high nasogastric outputs are identified; an option to be considered in these patients is to place a tube gastrostomy at the time of operation. We do not routinely administer postoperative antiemetics, preferring to evaluate complaints of nausea or emesis at the bedside to ensure there is no significant gastric dilation. Prokinetic agents such as metoclopramide or the motilin agonist erythromycin may be used in these patients to promote gastric emptying,17 but no prospective randomized trials are available to prove their effectiveness after gastrojejunostomy alone. We do not routinely administer these agents.
Sonnenday and Yeo
Our current practice is to offer limited sips of water and ice to the patient on the first postoperative day, with clear liquids ad libitum on the second postoperative day, and a regular diet on the third postoperative day. Many patients seem to best tolerate several small meals or snacks per day rather than three large meals. Delayed gastric emptying (DGE) is the most common complication after gastrojejunostomy and is of particularly high risk in patients with chronic gastric outlet obstruction. Patients with advanced age, diabetes mellitus, hypothyroidism, and autonomic disorders appear also to be at higher risk for DGE.18,19 A unique group of patients who appear to be at risk for DGE include those with an unresectable pancreatic cancer that is not mechanically obstructing the duodenum but who manifest symptoms of DGE preoperatively.20 While there is no definitive therapy for DGE, most patients have a self-limited course and are slowly able to initiate oral intake over time. Adjunctive strategies such as prokinetic agents, limitation of narcotics, and early return of physical activity may play some role in promoting normal motility. In patients unable to tolerate oral intake after 7 to 10 days, an upper GI series with diluted barium can evaluate the anatomy and establish that the anastomosis is patent. If the gastrojejunal anastomosis is tight or cannot be visualized by the upper GI series, upper endoscopy by a skilled endoscopist to evaluate the anastomosis is appropriate. In selected patients, it may be appropriate to intubate and gently balloon dilate the anastomosis. However, these measures are necessary only in the minority of cases, and patience will allow most patients to resolve early DGE without invasive intervention. Gastrojejunostomy has long been recognized as an ulcerogenic procedure. The incidence of marginal ulceration can be reduced by performance of vagotomy (if appropriate) and possibly by evaluation for and treatment of H. pylori infection. When vagotomy is not performed, we believe that most patients should be maintained on gastric acid suppression therapy, using either histamine H2-receptor antagonists or proton-pump inhibitors.
REFERENCES 1. Parsa CJ, Organ CH, Barkan H: Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 135:573–575, 2000 2. Csendes A, Maluenda F, Braghetto I, et al: Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg 166:45– 49, 1993 3. Jaffin BW, Kaye MD: The prognosis of gastric outlet obstruction. Ann Surg 201:176 –179, 1985 4. Millat B, Fingerhut A, Borie F: Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg 24:299 –306, 2000 5. DiSario JA, Fennerty MB, Tietze CC, et al: Endoscopic balloon dilatation for ulcer induced gastric outlet obstruction. Am J Gastroenterol 89:868 – 871, 1994 6. Lau JYW, Chung SCS, Sung JJY, et al: Through the scope balloon dilatation for pyloric stenosis: long term results. Gastrointest Endosc 43:98 –102, 1996
Open Gastrojejunostomy 7. Kennedy T, Johnston GW, Love AH, et al: Pyloroplasty versus gastrojejunostomy. Results of a double-blind, randomized trial. Br J Surg 60:949 –953, 1973 8. Aranha GV, Prinz RA, Greenlee HB, et al: Gastric outlet and duodenal obstruction from inflammatory pancreatic disease. Arch Surg 119:833– 835, 1984 9. Prinz RA, Aranha GV, Greenlee HB: Combined pancreatic duct and upper gastrointestinal and biliary tract drainage in chronic pancreatitis. Arch Surg 120:361–366, 1985 10. Delaney CP, Fazio VW: Crohn’s disease of the small bowel. Surg Clin North Am 81:137–158, 2001 11. Nugent FW, Roy MA: Duodenal Crohn’s disease: an analysis of 89 cases. Am J Gastroenterol 84:249 –254, 1989 12. Shellito PC, Warshaw AL: Idiopathic intermittent gastroparesis and its surgical alleviation. Am J Surg 148:408 – 412, 1984 13. Schirmer BD: Mechanical and motility disorders of the stomach and duodenum. In GD Zuidema, CJ Yeo (Eds): Shackelford’s Surgery of the Alimentary Tract (5th ed). Philadelphia: WB Saunders, 2002, pp 178 –184
79 14. Behrns KE, Sarr MG: Diagnosis and management of gastric emptying disorders. Adv Surg 27:233–255, 1994 15. Guy RJ, Dawson JL, Garrett JR, et al: Diabetic gastroparesis from autonomic neuropathy: surgical considerations and changes in vagus nerve morphology. J Neurol Neurosurg Psychiatry 47:686 – 691, 1984 16. Cullen JJ, Kelly KA: Gastric motor physiology and pathophysiology. Surg Clin North Am 73:1145–1160, 1993 17. Yeo CJ, Barry MK, Sauter PK, et al: Erythromycin accelerates gastric emptying following pancreaticoduodenectomy: a prospective, randomized placebo controlled trial. Ann Surg 218:229 –238, 1993 18. Kung SP, Lui WY, P’Eng FK: An analysis of the possible factors contributing to the delayed return of gastric emptying after gastrojejunostomy. Surg Today 25:911–915, 1995 19. Woods SD, Mitchell GJ: Delayed return of gastric emptying after gastroenterostomy. Br J Surg 76:145–148, 1989 20. Sarr MG, Gladen HE, Beart RW Jr., van Heerden JA: Role of gastroenterostomy in patients with unresectable carcinoma of the pancreas. Surg Gynecol Obstet 152:597– 600, 1981
hile the volume of gastric surgery performed in surgical training programs in the United States has decreased markedly in recent years with the virtual disappearance of elective ulcer operations,1 open gastrojejunostomy remains an important tool in the armamentarium of any general surgeon. Gastrojejunostomy is often performed to restore gastro-enteric continuity after resection or palliative bypass of malignant disease (gastric or periampullary), or as part of a gastric bypass procedure for morbid obesity. Further, gastrojejunostomy serves as a treatment option for benign obstruction to the gastric outlet or duodenum. This chapter will concentrate on the role of open gastrojejunostomy in the management of patients with benign disease.
W
INDICATIONS Open gastrojejunostomy may be indicated for any condition that functionally or mechanically impairs normal gastric emptying. Historically, the most common cause of gastric outlet obstruction requiring operative treatment has been peptic ulcer disease. Despite the recognition of Helicobacter pylori as a causative agent in peptic ulcer disease and the establishment of effective medical therapies, gastric outlet obstruction may occur in 6% to 8% of patients with chronic duodenal ulcer.2 Many of these patients may be managed initially with nonoperative therapy consisting of nasogastric suction, gastric acid inhibition, eradication of H. pylori, endoscopic dilation, and total parenteral nutrition. Those patients that fail nonoperative intervention require surgical therapy for persistent or recurrent obstruction.3,4 Endoscopic balloon dilation coupled with aggressive H. pylori therapy and high dose proton pump inhibition has been proposed as an alternative to surgical therapy, but recent trials report a symptomatic recurrence rate as high as 50%,5,6 with those patients experiencing a recurrence typically requiring surgical intervention. Gastrojejunostomy, accompanied by highly selective
From the The Johns Hopkins Medical Institutions, Baltimore,MD. *Note: All illustrations have been modified from Atlas of Surgery -Volume 2. Editor John L. Cameron; Illustrator Corinne Sandone; Mosby; St. Louis, 1994. Address reprint requests to Dr. Charles J. Yeo, Professor of Surgery and Oncology, The Johns Hopkins Hospital, Department of Surgery, Blalock 606, 600 N. Wolfe Street, Baltimore, MD 21287-4606. © 2003 Elsevier Inc. All rights reserved. 1524-153X/03/0502-0029$30.00/0 doi:10.1053/otgn.2003.35367
vagotomy (HSV), has been advocated as the primary nonresectional treatment of obstructing duodenal ulcer, because it appears to be a more effective gastric drainage procedure than pyloroplasty and carries a lower risk of perioperative morbidity and mortality than antrectomy.2,7 Csendes and colleagues2 compared gastrojejunostomy plus HSV, gastroduodenostomy plus HSV, or antrectomy plus HSV in a prospective trial and found both the gastrojejunostomy and antrectomy groups to have excellent and equivalent long-term outcomes. It is important to emphasize that gastrojejunostomy alone is not believed to be an adequate therapy for obstructing peptic ulcer disease and should be accompanied by vagotomy to prevent marginal ulceration at the gastrojejunal anastomosis. Chronic pancreatitis is another important cause of gastric outlet obstruction. While acute pancreatitis is often associated with transient gastroduodenal dysmotility, these patients rarely require operative intervention. While less than 1% of all patients with chronic pancreatitis will develop fixed duodenal stenosis, up to 25% of patients with complicated chronic pancreatitis will require surgery.8,9 Thorough evaluation of these patients is necessary to rule out other associated conditions which would mandate different therapy, such as peptic ulcer disease, pancreatic pseudocyst, or pancreatic ductal adenocarcinoma. Gastroduodenal obstruction secondary to duodenal stricture may occur in 1% to 3% of patients with Crohn’s disease.10 Approximately one-third of these patients may eventually need surgical treatment, and gastrojejunostomy rather than duodenoplasty is the procedure of choice in these patients.11 Again, vagotomy is recommended at the time of this procedure to reduce the incidence of marginal ulceration.10 Other rare causes of mechanical gastroduodenal obstruction that may be treated effectively with gastrojejunostomy include congenital duodenal obstruction (due to atresia, webs, or duplication), annular pancreas, and posttraumatic strictures of the pylorus or duodenum. Patients with severe functional impairment to gastric emptying, in the absence of a mechanical obstruction, present a tremendous challenge in management. Systemic disorders such as diabetes mellitus, various collagen-vascular diseases, and autonomic neuropathies may be associated with severe gastroparesis. Idiopathic gastric atony has also been reported.12 Patients with functional gastric
Operative Techniques in General Surgery, Vol 5, No 2 (June), 2003: pp 73–79
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outlet obstruction may be referred to surgeons after failed trials of the prokinetic agents. In some instances, attempts at gastric pacing may have been attempted and failed.13 Although no large series or prospective trials exist for this small group of patients, gastrojejunostomy has been reported to provide benefit but only in highly selected patients.12,14,15 However, partial or complete gastric resection may eventually be necessary in some patients. Patients with gastroparesis are at extremely high risk of persistent gastric emptying problems after primary drainage procedures (pyloroplasty, gastrojejunostomy, and even antrectomy), and therefore procedures such as truncal vagotomy (which may worsen gastric motility) should be avoided.16
PREOPERATIVE EVALUATION The goals of the preoperative evaluation for a patient with gastroduodenal obstruction are: (1) appropriate resuscitation; (2) nutritional supplementation; and (3) to definitively exclude causes of obstruction that would require other medical or surgical therapy, particularly malignancy. Patients with chronic gastroduodenal obstruction can present with impressive dehydration and malnutrition due to protracted decreased oral intake and vomiting. Electrolyte and acid-base disturbances, classically a contraction hypochloremic metabolic alkalosis with hypokalemia, should be promptly identified and corrected. Nasogastric decompression may cease the vomiting and allow relief of gastric distention. Total parenteral nutrition is often necessary to begin the correction of proteincalorie malnutrition. Operative intervention is usually delayed until adequate hydration and electrolyte correction are achieved and until nutritional repletion is begun. The diagnosis of gastroduodenal obstruction is often suspected based on the findings at history and physical examination, and it may be further supported by the appearance of a large gastric air bubble on plain radiography of the abdomen. Confirmatory tests such as an upper gastrointestinal (GI) series or computed tomography (CT) with oral contrast may further support the diagnosis and isolate the location of the obstruction. In patients without a clear mechanical obstruction, scintigraphic imaging using both solid and liquid phases (dual phase nuclear medicine gastric emptying scan) may document an abnormality in gastric emptying. Before proceeding to the operating room for surgical therapy, it is usually essential that the mucosa of the stomach and duodenum be examined endoscopically in an effort to define the cause (and possibly the site) of the obstruction. Any thickened, inflamed, or ulcerated regions of the mucosa should be sampled, with the goal being to assess for malignancy, Crohn’s disease and H. pylori status. Other imaging studies such as CT, magnetic resonance, and endoscopic ultrasonography may be help-
ful in defining the underlying cause of the gastroduodenal obstruction.
TECHNICAL CONSIDERATIONS Antecolic Gastrojejunostomy. Open antecolic gastrojejunostomy is typically performed via an upper midline incision. If a nasogastric tube was not placed preoperatively, then such a tube is placed either immediately before or after the induction of general anesthesia to decompress the stomach. As always, careful inspection of the abdominal contents is performed, paying particular attention to the stomach, duodenum, and upper abdomen for any pathology not suspected in the preoperative evaluation. Any suspicious masses should be sent for frozen section analysis. The dependent portion of the greater curvature of the stomach is identified and cleared of the gastrocolic omentum. Typically the gastroepiploic arcade is divided along the gastric greater curvature (Fig 1). Some surgeons prefer to create the anastomosis equidistantly between the lesser and greater curvatures of the stomach, thereby avoiding the need to ligate any vessels along the greater curvature. The transverse colon with its attached greater omentum is then retracted cephalad, and the ligament of Treitz and proximal jejunum are identified (Fig 2). A gentle loop of proximal jejunum is brought up in an antecolic fashion without any associated tension and approximated to the greater curvature of the stomach where the greater curvature has been exposed. It is appropriate to create a relatively short afferent loop, however, it is important not to make the length of the afferent loop so short that it compresses the transverse colon. Our preferred technique of gastrojejunal anastomosis is performed by initially placing a posterior outer layer of 3– 0 silk seromuscular sutures (Fig 3). The gastrojejunal anastomosis is usually made 3 to 4 cm in length. Linear openings are then created within the stomach (as depicted in Fig 3) and subsequently in the jejunum adjacent to the posterior outer layer of 3– 0 silk sutures. Next, the inner layer of the posterior row is performed using a continuous locking suture of 3– 0 absorbable synthetic material (Fig 4). This suture is then brought anterior as the inner layer of the anterior row using a Connell technique. After the inner layer of the anterior row is completed, an outer layer of the anterior row is placed using interrupted 3– 0 silk seromuscular sutures. The final configuration of a typical antecolic gastrojejunostomy is shown in Fig 5. There are many alternative suturing techniques for performing a gastrojejunostomy. Additionally, stapling devices such as a linear stapler or a circular stapler can be used. In a considerable proportion of patients, an antecolic gastrojejunostomy does not appear to empty nearly as effectively as a retrocolic gastrojejunostomy. For this reason, our preference is to perform a retrocolic gastrojejunostomy in most patients who require open gastrojejunostomy.
1
The abdomen is entered through an upper midline incision and thoroughly explored. If an antecolic gastrojejunostomy is to be performed, then the most dependent portion of the gastric greater curvature is identified and cleared of omentum over a distance of 6 to 8 cm. The gastroepiploic arcade is typically left intact, caudal to the opening in the gastrocolic omentum.
2
The transverse colon is elevated with its omentum attached, and the ligament of Treitz and proximal jejunum are identified. A mobile loop of proximal jejunum is then brought up in an antecolic fashion, insuring that the afferent limb of the gastrojejunostomy does not compress the transverse colon.
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3
After approximating the gastric greater curvature and the mobile loop of proximal jejunum, the anastomosis is commenced. The anastomosis is performed by initially placing a posterior outer layer of 3– 0 silk Lembert sutures between the stomach and the jejunum. After insuring that the stomach has been decompressed via a nasogastric tube, a linear 3 to 4 cm gastrotomy is created. A parallel opening is then made in the jejunum, adjacent to the anterior gastrotomy.
4
The afferent and efferent limbs of jejunum are controlled with noncrushing clamps. The inner layer of the posterior row of the gastrojejunal anastomosis is placed using a continuous locking suture of 3– 0 synthetic absorbable material. This suture is continued anteriorly as the inner layer of the anterior row using a Connell stitch. The inner layer of the anterior row is then completed, and the noncrushing intestinal clamps are removed.
Retrocolic Gastrojejunostomy. After initial abdominal exploration, the most dependent portion of the greater curvature of the stomach is cleared of omentum, as was shown in the initial step of an antecolic gastrojejunostomy (Fig 1). An opening is then made bluntly in the transverse mesocolon, avoiding the mesocolic vessels (which run vertically), and typically a bit to the left of the midline and to the left of the middle colic vessels. A proximal loop of jejunum is brought through this rent in the transverse mesocolon (Fig 6), and the anastomosis is performed above the mesocolon in a fashion similar to that of an antecolic gastrojejunostomy (Fig 7). The completed anastomosis, which lies above the transverse mesocolon should not be left in this position. The gastrojejunostomy is then pulled down through the transverse mesocolon, and the transverse mesocolon is tacked to the stomach, circumferentially, at least 1 cm above the gastrojejunal anastomosis (Fig 8), thereby fixing the jejunal loop below the mesocolon. This will prevent an obstruction of the jejunum by the mesocolon.
POSTOPERATIVE CARE The primary principles of management of patients after gastrojejunostomy are: (1) ensuring continued adequate nutrition and hydration; (2) slow resumption of oral intake; and (3) anticipation of possible complications in-
5
The outer layer of the anterior row is completed using 3– 0 silk Lembert sutures. The final anatomy of an antecolic gastrojejunal anastomosis is shown here. There are no mesenteric defects to close, and no rents in the gastrocolic omentum or transverse mesocolon to repair.
6
The performance of a retrocolic gastrojejunostomy commences with similar maneuvers as for the antecolic gastrojejunal anastomosis. As shown in Fig 1, the greater omentum is cleared from the most dependent portion of the gastric greater curvature for a distance of 6 to 8 cm. Next, an opening is then made in the transverse mesocolon, usually to the left of the middle colic vessels, avoiding injury to major vessels within the mesocolon. A proximal loop of jejunum is brought through the transverse mesocolon, and the gastrojejunal anastomosis is performed above the transverse mesocolon, with the stomach and the jejunum approximated side-by-side. Note that for a retrocolic gastrojejunostomy, the length of the afferent limb can be shorter than for an antecolic gastrojejunostomy.
7
The completed retrocolic gastrojejunal anastomosis using an outer layer of interrupted 3– 0 silk Lembert sutures and an inner layer of running 3– 0 synthetic absorbable suture. It is important that the anastomosis not be left in this supramesocolic position, as the narrow opening in the transverse mesocolon can serve as an obstruction to the afferent and efferent jejunal limbs.
78
8
The gastrojejunal anastomosis is pulled down through the transverse mesocolon, and the transverse mesocolon is tacked to the stomach approximately 1 cm cephalad to the gastrojejunal anastomosis. Using this maneuver, the most dependent portion of the gastric greater curvature remains dependent, and the afferent and efferent limbs of the gastrojejunostomy reside entirely beneath the transverse mesocolon without the risk of obstruction by the mesocolon itself.
cluding delayed gastric emptying and marginal ulcer formation. Fluid and electrolyte replacement are standard, with attention to any preoperative deficits that may require further supplementation. Parenteral or enteral nutrition initiated in the preoperative period should be continued into the postoperative period until adequate oral intake can be established. Typically, we remove the nasogastric tube on the morning of the first postoperative day, as long as the output has not been excessive (greater than 500 to 1000 mL per 24 hours) and as long as the gastric pH is neutral (ie, acid secretion is suppressed pharmacologically). One exception to this practice of early nasogastric tube removal is the patient with a chronically dilated stomach that might be anticipated to be slow to regain motility, where high nasogastric outputs are identified; an option to be considered in these patients is to place a tube gastrostomy at the time of operation. We do not routinely administer postoperative antiemetics, preferring to evaluate complaints of nausea or emesis at the bedside to ensure there is no significant gastric dilation. Prokinetic agents such as metoclopramide or the motilin agonist erythromycin may be used in these patients to promote gastric emptying,17 but no prospective randomized trials are available to prove their effectiveness after gastrojejunostomy alone. We do not routinely administer these agents.
Sonnenday and Yeo
Our current practice is to offer limited sips of water and ice to the patient on the first postoperative day, with clear liquids ad libitum on the second postoperative day, and a regular diet on the third postoperative day. Many patients seem to best tolerate several small meals or snacks per day rather than three large meals. Delayed gastric emptying (DGE) is the most common complication after gastrojejunostomy and is of particularly high risk in patients with chronic gastric outlet obstruction. Patients with advanced age, diabetes mellitus, hypothyroidism, and autonomic disorders appear also to be at higher risk for DGE.18,19 A unique group of patients who appear to be at risk for DGE include those with an unresectable pancreatic cancer that is not mechanically obstructing the duodenum but who manifest symptoms of DGE preoperatively.20 While there is no definitive therapy for DGE, most patients have a self-limited course and are slowly able to initiate oral intake over time. Adjunctive strategies such as prokinetic agents, limitation of narcotics, and early return of physical activity may play some role in promoting normal motility. In patients unable to tolerate oral intake after 7 to 10 days, an upper GI series with diluted barium can evaluate the anatomy and establish that the anastomosis is patent. If the gastrojejunal anastomosis is tight or cannot be visualized by the upper GI series, upper endoscopy by a skilled endoscopist to evaluate the anastomosis is appropriate. In selected patients, it may be appropriate to intubate and gently balloon dilate the anastomosis. However, these measures are necessary only in the minority of cases, and patience will allow most patients to resolve early DGE without invasive intervention. Gastrojejunostomy has long been recognized as an ulcerogenic procedure. The incidence of marginal ulceration can be reduced by performance of vagotomy (if appropriate) and possibly by evaluation for and treatment of H. pylori infection. When vagotomy is not performed, we believe that most patients should be maintained on gastric acid suppression therapy, using either histamine H2-receptor antagonists or proton-pump inhibitors.
REFERENCES 1. Parsa CJ, Organ CH, Barkan H: Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 135:573–575, 2000 2. Csendes A, Maluenda F, Braghetto I, et al: Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg 166:45– 49, 1993 3. Jaffin BW, Kaye MD: The prognosis of gastric outlet obstruction. Ann Surg 201:176 –179, 1985 4. Millat B, Fingerhut A, Borie F: Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg 24:299 –306, 2000 5. DiSario JA, Fennerty MB, Tietze CC, et al: Endoscopic balloon dilatation for ulcer induced gastric outlet obstruction. Am J Gastroenterol 89:868 – 871, 1994 6. Lau JYW, Chung SCS, Sung JJY, et al: Through the scope balloon dilatation for pyloric stenosis: long term results. Gastrointest Endosc 43:98 –102, 1996
Open Gastrojejunostomy 7. Kennedy T, Johnston GW, Love AH, et al: Pyloroplasty versus gastrojejunostomy. Results of a double-blind, randomized trial. Br J Surg 60:949 –953, 1973 8. Aranha GV, Prinz RA, Greenlee HB, et al: Gastric outlet and duodenal obstruction from inflammatory pancreatic disease. Arch Surg 119:833– 835, 1984 9. Prinz RA, Aranha GV, Greenlee HB: Combined pancreatic duct and upper gastrointestinal and biliary tract drainage in chronic pancreatitis. Arch Surg 120:361–366, 1985 10. Delaney CP, Fazio VW: Crohn’s disease of the small bowel. Surg Clin North Am 81:137–158, 2001 11. Nugent FW, Roy MA: Duodenal Crohn’s disease: an analysis of 89 cases. Am J Gastroenterol 84:249 –254, 1989 12. Shellito PC, Warshaw AL: Idiopathic intermittent gastroparesis and its surgical alleviation. Am J Surg 148:408 – 412, 1984 13. Schirmer BD: Mechanical and motility disorders of the stomach and duodenum. In GD Zuidema, CJ Yeo (Eds): Shackelford’s Surgery of the Alimentary Tract (5th ed). Philadelphia: WB Saunders, 2002, pp 178 –184
79 14. Behrns KE, Sarr MG: Diagnosis and management of gastric emptying disorders. Adv Surg 27:233–255, 1994 15. Guy RJ, Dawson JL, Garrett JR, et al: Diabetic gastroparesis from autonomic neuropathy: surgical considerations and changes in vagus nerve morphology. J Neurol Neurosurg Psychiatry 47:686 – 691, 1984 16. Cullen JJ, Kelly KA: Gastric motor physiology and pathophysiology. Surg Clin North Am 73:1145–1160, 1993 17. Yeo CJ, Barry MK, Sauter PK, et al: Erythromycin accelerates gastric emptying following pancreaticoduodenectomy: a prospective, randomized placebo controlled trial. Ann Surg 218:229 –238, 1993 18. Kung SP, Lui WY, P’Eng FK: An analysis of the possible factors contributing to the delayed return of gastric emptying after gastrojejunostomy. Surg Today 25:911–915, 1995 19. Woods SD, Mitchell GJ: Delayed return of gastric emptying after gastroenterostomy. Br J Surg 76:145–148, 1989 20. Sarr MG, Gladen HE, Beart RW Jr., van Heerden JA: Role of gastroenterostomy in patients with unresectable carcinoma of the pancreas. Surg Gynecol Obstet 152:597– 600, 1981