Why is jejunojejunostomy (jejunum to jejunum connection) often performed with gastrojejunostomy (stomach to jejunum connection)?

Why Jejunojejunostomy is Performed with Gastrojejunostomy

Jejunojejunostomy is performed with gastrojejunostomy to prevent bile reflux, allow proper intestinal flow, and reduce the risk of delayed gastric emptying, which significantly improves patient outcomes by preventing complications like circulus vomiting and malnutrition. 1

Anatomical and Functional Reasons

When a gastrojejunostomy (stomach to jejunum connection) is created, it disrupts the normal flow of digestive contents. A complementary jejunojejunostomy serves several critical purposes:

1. Prevention of "Circulus Vomiting":

   • Without a jejunojejunostomy, food can re-enter the duodenum and proximal jejunum from the gastrojejunostomy site, creating a circular path that leads to vomiting
   • Studies show "food reentry" occurs in approximately 21% of patients with simple gastrojejunostomy without jejunojejunostomy 1

2. Bile Diversion:

   • Jejunojejunostomy creates a pathway for bile and pancreatic secretions to bypass the gastrojejunostomy
   • This prevents reflux of bile into the stomach, which can cause significant gastritis and discomfort

3. Improved Gastric Emptying:

   • Gastric emptying time is significantly better when proper intestinal flow is maintained with a jejunojejunostomy
   • Patients with duodenal partition and proper jejunojejunostomy resume oral diet approximately 3.5 days earlier than those with simple gastrojejunostomy 1

Clinical Applications

The gastrojejunostomy-jejunojejunostomy combination is commonly used in:

1. Palliative Procedures for Unresectable Cancer:

   • For patients with pancreatic adenocarcinoma causing gastric outlet obstruction
   • The National Comprehensive Cancer Network recommends gastrojejunostomy with jejunojejunostomy for durable palliation of gastric outlet obstruction 2

2. Bypass Procedures:

   • When duodenal obstruction requires bypassing the duodenum
   • Laparoscopic gastrojejunostomy with jejunojejunostomy shows better outcomes regarding resumption of oral feeding (median 2 days vs 4 days for open procedures) 3

3. Nutritional Access:

   • When creating feeding access that bypasses the stomach and duodenum
   • Gastrojejunostomy with jejunojejunostomy allows for both gastric decompression and jejunal feeding 2

Technical Considerations

The technical aspects of creating these anastomoses are important:

• Roux-en-Y Configuration: The most common arrangement, where the jejunum is divided and the distal end is connected to the stomach (gastrojejunostomy), while the proximal end is reconnected to the jejunum further downstream (jejunojejunostomy)

• Placement Distance: The jejunojejunostomy is typically created approximately 40-60cm distal to the gastrojejunostomy to prevent bile reflux while maintaining proper intestinal flow 1

• Success Rates: Percutaneous gastrojejunostomy procedures have success rates ranging from 90-100%, with proper jejunal placement being critical to success 2

Potential Complications Without Jejunojejunostomy

Failure to create a proper jejunojejunostomy when performing a gastrojejunostomy can lead to:

• Delayed gastric emptying (26.1% in simple gastrojejunostomy vs 0% when proper configuration is used) 3
• Bile reflux gastritis
• Malnutrition due to inadequate nutrient absorption
• Prolonged hospital stays
• Increased risk of aspiration pneumonia

Conclusion

The addition of jejunojejunostomy to gastrojejunostomy is not merely optional but essential for proper gastrointestinal function when bypassing the duodenum. It prevents the circular flow of intestinal contents, diverts bile appropriately, and significantly improves clinical outcomes by allowing earlier resumption of oral intake and reducing complications like delayed gastric emptying.