Steps of Open Gastrojejunostomy
The open gastrojejunostomy procedure involves creating an anastomosis between the stomach and jejunum, which can be performed using several standardized techniques with high success rates of 90-100%. 1
Preoperative Preparation
- Patient should be kept nil per os (NPO) past midnight for a procedure the following day, though clear liquids may be provided up to 2 hours before the procedure to reduce aspiration risk 1
- Antibiotic prophylaxis with a first-generation cephalosporin or similar agent that covers typical cutaneous organisms should be administered, especially for patients at high risk of infection 1
- Coagulation parameters should be optimized before the procedure, with INR less than 1.5 and platelet count greater than 50,000/L 1
Surgical Approach and Technique
Initial Access and Gastric Preparation
- Make a midline laparotomy incision to access the abdominal cavity 2
- Identify and mobilize the stomach, ensuring proper exposure of the anterior gastric wall 1
- Position the gastrostomy to the right of midline and lower in the antrum to allow for a shorter, more direct route for the jejunal tube through the pylorus 1
- This positioning will minimize gastric looping and help prevent proximal migration of the jejunal component 1
Jejunal Preparation
- Identify a loop of jejunum approximately 20 cm distal to the ligament of Treitz 3
- Mobilize the selected jejunal segment to ensure it can reach the stomach without tension 2
Creating the Anastomosis
- Make an incision in the anterior wall of the stomach 1
- Create a corresponding enterotomy in the selected jejunal segment 2
- Secure the jejunal loop to the stomach using sutures, creating the gastrojejunostomy 4
- The anastomosis can be created using various techniques:
Tube Placement (If Applicable)
- For feeding gastrojejunostomy tubes:
- Insert the gastrostomy tube through the abdominal wall into the stomach 1
- Advance the jejunal extension tube through the gastrostomy tube, through the pylorus, and into the jejunum beyond the ligament of Treitz 1
- Use fluoroscopic guidance to confirm proper positioning of the jejunal extension tube 1
- Secure the tube in place and confirm patency by injecting contrast material 1
Closure
- Secure the anastomosis with a second line of sutures if needed 4
- Close the abdominal wall in layers using standard technique 2
Post-Procedure Management
- Confirm tube placement with contrast study before initiating feedings 4
- For feeding tubes, continuous rather than bolus feeding through the jejunal port is required due to loss of the stomach reservoir 5
- Monitor for complications including:
Special Considerations
- In patients with ascites, malnourishment, or steroid treatment, gastropexy sutures are imperative to prevent leakage 1
- For patients with upper GI stenosis, image-guided jejunostomy is favored as it prevents the need for endoscope passage 1
- Success rates for percutaneous gastrojejunostomy range from 90% to 100%, with similar outcomes between endoscopy-guided and fluoroscopy-guided techniques 1
Common Pitfalls and How to Avoid Them
- Tube dislocation or migration: Cutting the external gastrostomy tube length to shorter than 10 cm and using an extension tube of longer length will allow for deeper and more stable position in the jejunum 1
- Gastric looping: Position the gastrostomy to the right of midline and lower in the antrum to create a more direct route for the jejunal tube 1
- Difficult jejunal access: When the gastrostomy tube faces away from the pylorus, use a stiff wire or sometimes two wires to overcome this obstacle 1
- Infection risk: Proper antibiotic prophylaxis and aseptic technique are essential to prevent peristomal infection 1