Gastrojejunostomy

Overview

A gastrojejunostomy involves the surgical creation of a new connection, or anastomosis, between the stomach and the jejunum, the middle section of the small intestine. This procedure redirects the flow of food from the stomach to the jejunum, bypassing the duodenum, which is the initial portion of the small intestine. In some cases, the term “gastrojejunostomy” may also be used to refer to a minor intervention for placing a feeding tube in the small intestine, known as a gastrojejunostomy tube. This tube, passing through the stomach and duodenum, facilitates nutrition delivery directly to the jejunum, a procedure distinct from percutaneous gastrojejunostomy.

Reasons for undergoing the procedure

A gastrojejunostomy may be necessary if your duodenum or lower stomach (antrum) faces medical issues, such as blockages or dysfunction. In cases where the outlet at the bottom (pylorus) hinders food passage, connecting the small intestine to the upper part of the stomach through gastrojejunostomy can provide a solution. Additionally, gastrojejunostomy is a component of weight loss surgery, exemplified by the Roux-en-Y gastric bypass, where a portion of the stomach and the duodenum are bypassed to reduce food capacity in the stomach and limit nutrient absorption in the small intestine.

Gastrojejunostomy may be recommended for the treatment of various conditions:

• Gastric outlet obstruction (GOO): Occurs when the outlet at the bottom of the stomach is blocked.
• Duodenal obstruction: Involves obstruction in the duodenum.
• Stomach or duodenal cancer: Necessary when cancer causes obstruction or requires the resection of part of the stomach or duodenum.
• Peptic ulcer disease: Required when complications like bleeding or scarring impede the passage of food through the stomach or duodenum.

Less commonly, a preventative gastrojejunostomy may be performed in the following situations:

• Severe duodenal trauma: Recommended if the surgeon believes there’s a high risk of developing a fistula in the injured duodenum. Diverting food away during the healing process helps avoid complications, such as the formation of an abnormal tunnel to the pancreas due to persistent inflammation.
• Non-removable pancreatic cancer: Considered if cancer in the pancreas, near the duodenum, cannot be removed. This procedure prevents the potential growth of the cancer, obstructing the outlet between the stomach and duodenum, and ensures the redirection of the gastrointestinal tract to mitigate risks.

Risks

Surgical procedures, including gastrojejunostomy, involve inherent risks like bleeding, blood clots, organ damage, and excessive internal scar tissue formation. In the case of gastrojejunostomy, there is an additional risk of anastomotic leak, a rare occurrence where fluids may escape from the newly established connection between the stomach and intestines. This leakage poses the potential for abdominal infections, and if it extends to the bloodstream, it could trigger a severe and life-threatening reaction known as sepsis.

Possible long-term side effects of gastrojejunostomy include:

• Dumping syndrome: A common but usually temporary side effect, dumping syndrome manifests as a collection of symptoms occurring after eating. Food rapidly passing from the stomach to the small intestine may cause symptoms like nausea, bloating, and indigestion. These symptoms tend to improve as the digestive system adjusts over time.
• Bile reflux: The pylorus, a valve separating the stomach and duodenum, normally prevents digestive juices, including bile, from entering the stomach. By bypassing the pylorus and duodenum, there is a risk that the new connection between the stomach and small intestine may not effectively prevent bile reflux. This can lead to irritation of the stomach lining.
• Marginal ulcer: Peptic ulcers typically form in the stomach or duodenum, where they can be neutralized by stomach acids. However, when the duodenum is bypassed during gastrojejunostomy, stomach acids directly enter the jejunum, potentially causing ulcers in this part of the intestine.

It’s crucial to note that these long-term side effects are potential complications that may arise, and individual experiences can vary. Patients should thoroughly discuss the risks and benefits of the procedure with their healthcare providers before making informed decisions about surgery.

Before the procedure

Before undergoing surgery, your healthcare team will assess your overall health, especially if you’re experiencing conditions such as gastrointestinal tract blockages. Common symptoms may include difficulty keeping food down, frequent vomiting, dehydration, and malnourishment.

To optimize your health for surgery, your healthcare team may administer the following treatments:

• Intravenous (IV) fluids: Customized intravenous fluids will be provided to correct any electrolyte imbalances.
• Intravenous (IV) nutrition: Supplemental or total nutrition can be delivered through an intravenous route to address nutritional deficiencies.
• Blood transfusion: If you are anemic, you may receive additional blood to improve your overall blood count.
• Antibiotics: Prophylactic antibiotics may be administered before surgery to reduce the risk of infections.
• Gastric decompression: This involves the placement of a nasogastric tube down your throat into the stomach. The tube helps remove stomach contents, relieving pressure and ensuring a safer administration of anesthesia.

During the procedure

The gastrojejunostomy procedure typically involves the following steps:

• Anesthesia: You will be administered general anesthesia to ensure you are asleep and pain-free during the surgery.
• Gastric decompression: a nasogastric or orogastric tube will be inserted into your stomach to relieve pressure and remove any excess fluids.
• Abdominal access: Your surgeon will access your abdominal cavity using either an open or laparoscopic (minimally invasive) approach.
• Problem identification: The surgeon will locate the issue within your stomach or duodenum that requires removal or exclusion.
• Jejunal loop preparation: A segment of the jejunum, typically at least 10 centimeters from the end of the duodenum, will be measured out.
• Jejunal stomach attachment: The identified loop of jejunum will be surgically attached to your stomach, with a minimum distance of 5 centimeters above the problem area.
• Leak check: The newly created connection (anastomosis) will be carefully inspected for any signs of leaks using various techniques.
• Incision closure: The incisions made during the procedure will be closed, and the surgery will be completed.

The gastrojejunostomy procedure typically lasts between two to four hours.

After the procedure

After the surgery, you’ll be hospitalized, and it may take some time before you can tolerate solid food. You might experience nausea or delayed bowel movements (paralytic ileus). Additionally, the stomach might empty slowly through the new connection, and some individuals may require a nasogastric tube for several days. Initially, you may receive IV fluids and nutrition, or you could begin with a clear liquid diet, gradually transitioning to a soft diet before discharge. In certain instances, it may take several weeks for your stomach to regain normal function post-surgery, necessitating continued tube or IV feeding.

Outcome

Recovery duration: The average recovery time after surgery typically spans around six weeks. However, this duration may vary depending on the extent of your surgical procedure and whether it was performed using open or laparoscopic techniques. In some cases, the surgery may involve the division or removal of a portion of your stomach and small intestine. For patients undergoing surgery for cancer, additional tissue removal may have been necessary.

Postoperative care: Your healthcare team will provide you with essential instructions for caring for your incision wounds, managing pain at home, and determining when you can resume your regular activities. A follow-up appointment with your healthcare provider will be scheduled a few weeks after you are discharged to monitor your recovery progress and identify any potential complications.

Dietary considerations: Following surgery, you may be required to adhere to a special diet for several months. The specifics of this diet will depend on the extent of stomach and/or intestine removal and whether you are experiencing symptoms of dumping syndrome. It may necessitate heightened attention to your nutritional intake, including the possible use of vitamin supplements, and the avoidance of high-sugar foods.

You should promptly get in touch with your healthcare team if you encounter any of the following issues:

• Signs of wound infection, such as redness, pain, warmth, or swelling.
• A fever exceeding 100 degrees Fahrenheit (38 degrees Celsius).
• Difficulty in managing your pain.
• Challenges with eating or retaining food.
• Persistent diarrhea.
• Yellowing of your skin or the whites of your eyes.

Your health and well-being are of utmost importance, and timely communication with your healthcare professionals is crucial to ensure a smooth recovery process.