What is a gastrojejunostomy?

Gastrojejunostomy: Definition and Clinical Applications

A gastrojejunostomy is the creation of access to the jejunum through the stomach, allowing for feeding and/or decompression of the gastrointestinal tract. 1 This procedure creates a connection that bypasses the duodenum, enabling direct access to the jejunum either for nutritional support or gastrointestinal decompression.

Types and Techniques

Gastrojejunostomy can be performed using several approaches:

• Percutaneous Gastrojejunostomy (PEG-J): A jejunal extension tube is placed through an existing gastrostomy tube
• Surgical Gastrojejunostomy: Created during open or laparoscopic surgery
• Image-guided Gastrojejunostomy: Placed using fluoroscopy guidance

The procedure typically involves:

1. Initial access to the stomach (either through an existing gastrostomy or creating one)
2. Advancement of a tube through the stomach into the jejunum
3. Securing the tube in position

Clinical Indications

Gastrojejunostomy serves two primary purposes:

1. Enteral Feeding

• When gastric feeding is contraindicated:
  • Severe gastroesophageal reflux with aspiration risk
  • Gastroparesis or gastric outlet obstruction
  • Post-bariatric surgery requiring enteral access 2
  • Pancreatitis (jejunal feeding has shown improved outcomes) 1

2. GI Decompression

• For patients with:
  • GI obstruction
  • GI fistula
  • Need for concurrent feeding and decompression 1

Technical Considerations

When placing a gastrojejunostomy:

• Stomach puncture should be performed in the direction of the pylorus to facilitate jejunal tube placement 1
• Positioning the gastrostomy to the right of midline and lower in the antrum allows for a shorter, more direct route for the jejunal tube 1
• A stiff wire or sometimes two wires may be needed to overcome the angle challenge when the gastrostomy tube faces away from the pylorus 1

Success Rates and Complications

• Success rates for percutaneous gastrojejunostomy range from 90% to 100% 1
• No significant differences in success or complication rates between endoscopy-guided and fluoroscopy-guided gastrojejunal feeding tubes 1

Common complications include:

• Tube dislocation or migration
• Tube obstruction
• Inadvertent displacement of the tube back into the stomach 2
• Gastrojejunal stoma obstruction (rare complication) 3

Advantages Over Other Enteral Access Methods

• Some gastrojejunostomy tube systems have two ports—one into the stomach and one into the small intestine—allowing for concurrent jejunal feeding and gastric decompression 1
• Direct small bowel access has shown improved clinical results compared with gastric decompression tubes in cases of small bowel obstruction 1

Clinical Applications in Specific Scenarios

• Palliative Care: Gastrojejunostomy can provide a bypass for unresectable gastric or periampullary cancer 4
• Trauma Cases: May be part of surgical management in complex trauma involving the duodenum 3
• Long-term Enteral Access: When prolonged jejunal feeding is anticipated

For patients who cannot tolerate gastric feeding but require long-term jejunal access, direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as an alternative to PEG-J, with high success rates (92%) when using advanced endoscopic techniques 5.