What is involved in the construction of a gastrojejunostomy?

Construction of a Gastrojejunostomy

A gastrojejunostomy is the creation of access to the jejunum through the stomach, typically involving a tube with two ports that allows for simultaneous jejunal feeding and gastric decompression. 1

Definition and Structure

• A gastrojejunostomy creates artificial access between the stomach and jejunum, allowing for feeding and/or decompression through a tube that passes from the stomach into the small intestine 2, 1
• The tube typically has two ports - one opening into the stomach for decompression and another extending into the jejunum for feeding 1
• This dual-function capability makes it particularly valuable for patients requiring both nutritional support and gastric decompression 2, 1

Placement Methods

Preoperative Preparation

• Patients should be kept NPO (nil per os) before the procedure to reduce aspiration risk 3
• Antibiotic prophylaxis with coverage for cutaneous organisms is recommended 3
• Coagulation parameters should be optimized (INR <1.5, platelets >50,000/L) 3

Technical Approaches

• Transabdominal approach: The gastrojejunostomy tube is inserted through the abdominal wall into the stomach with extension into the jejunum 2
• Endoscopic guidance: Uses endoscopic equipment to visualize the intestinal tract during placement 2, 1
• Image guidance (fluoroscopy): Uses imaging to guide placement and confirm proper positioning 2, 3
• Conversion of existing gastrostomy: An existing gastrostomy can be converted to a gastrojejunostomy by adding a jejunal extension 1

Surgical Technique

1. Gastric access: The stomach is accessed through the abdominal wall, ideally positioned to the right of midline and lower in the antrum 2, 3
2. Gastropexy: The stomach is secured to the abdominal wall using T-fasteners or sutures 2, 3
3. Jejunal access: A wire is advanced through the pylorus into the small intestine beyond the ligament of Treitz 2, 3
4. Tube placement: The gastrojejunostomy tube is placed over the wire, with the jejunal extension positioned in the small intestine 2, 3
5. Position confirmation: Proper positioning is confirmed using contrast material under fluoroscopy 3

Key Technical Considerations

• The gastrostomy position should be 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 2, 3
• This positioning minimizes gastric looping and helps prevent proximal migration of the jejunal component 2, 3
• A stiff wire, or sometimes two wires, may be needed to overcome difficult angles when advancing the jejunal tube through the pylorus 2, 3
• Success rates for percutaneous gastrojejunostomy range from 90% to 100% 2, 3

Clinical Indications

• Simultaneous feeding and decompression in patients with GI obstruction or fistula 2, 1
• Small bowel feeding during episodes of pancreatitis, which has demonstrated improved outcomes compared to parenteral nutrition 2, 1
• Patients requiring jejunal feeding to bypass the stomach while maintaining gastric decompression 1

Complications and Management

• Mechanical issues such as tube kinking, coiling in the stomach, or migration 1, 3
• Tube dislocation can be avoided by cutting the external gastrostomy tube to shorter than 10 cm 3
• Continuous rather than bolus feeding through the jejunal port is required due to loss of the stomach reservoir 1, 3
• Gastrointestinal symptoms including diarrhea, abdominal distension, and dumping syndrome may occur 1

Alternative Techniques

• Roux-en-Y gastrojejunostomy: A surgical alternative that creates a permanent connection between the stomach and jejunum 4
• EUS-guided gastrojejunostomy: A newer, minimally invasive approach using lumen-apposing metal stents 5
• Direct percutaneous jejunostomy: An alternative when the stomach is inaccessible or after gastrectomy 6