Management of Patients Undergoing Gastroduodenectomy with Gastrojejunostomy
For patients undergoing gastroduodenectomy with gastrojejunostomy, postoperative management should focus on nasogastric tube decompression, careful monitoring for complications, and staged advancement of nutrition to optimize outcomes and reduce morbidity and mortality. 1
Indications and Surgical Considerations
- Gastroduodenectomy with gastrojejunostomy is indicated for massive disruption of the duodeno-pancreatic complex (WSES class III injuries, AAST-OIS grade III-V), particularly when primary repair or resection with primary anastomosis is not possible 1
- This procedure is commonly performed in cases of severe duodenal injuries located in the first or proximal second duodenal portion, involving antrectomy with gastrojejunostomy and closure of the duodenum 1
- For patients with malignant gastric outlet obstruction with life expectancy greater than 2 months and good functional status, laparoscopic gastrojejunostomy is preferred over open procedures due to lower blood loss and shorter hospital stay 2
Immediate Postoperative Management
- Place a nasogastric tube for proximal decompression to reduce pressure on the anastomosis and prevent complications 1
- Monitor for delayed bowel function and obstruction from duodenal edema, hematoma, or stricture, which are common following duodenal injuries 1
- Consider damage control surgery (DCS) with temporary abdominal closure in hemodynamically unstable patients with severe peritonitis or septic shock 1
- Implement early thromboprophylaxis with anticoagulation at prophylactic doses and consider pneumatic compression devices to prevent venous thromboembolism 3
Nutritional Support
- Initiate tube feeding within 24 hours after surgery if indicated, particularly in malnourished patients 1
- Start tube feeding with a low flow rate (10-20 ml/h) and increase carefully due to limited intestinal tolerance; reaching target intake may take 5-7 days 1
- Consider placement of a nasojejunal tube or needle catheter jejunostomy for all candidates for tube feeding undergoing major upper gastrointestinal and pancreatic surgery 1
- Total parenteral nutrition may be required in 37-75% of patients following complex duodeno-pancreatic procedures due to intolerance to enteral nutrition 1
Monitoring for Complications
- Closely monitor for duodenal-specific morbidity including duodenal leak, fistula, and anastomotic breakdown, which can lead to abdominal sepsis 1
- Watch for delayed gastric emptying, which occurs in up to 50% of patients after gastrojejunostomy due to food contents accumulating in the antrum 2
- Be vigilant for bile reflux gastritis, which can occur even with Roux-en-Y reconstruction 4
- Monitor for marginal ulcers at the gastrojejunal anastomosis, particularly in patients with history of peptic ulcer disease 5
Special Considerations
- For patients with malignant obstruction, laparoscopic gastrojejunostomy has shown excellent results with less suppression of immune function, lower morbidity, and earlier recovery of bowel movements compared to open procedures 6
- Recent evidence suggests that endoscopic ultrasound-guided gastroenterostomy (EUS-GE) may be superior to surgical gastrojejunostomy for malignant gastric outlet obstruction in terms of faster advancement to solid diet, shorter hospitalization, better quality of life, and lower treatment costs 7
- Poor nutritional status, ascites, and poor functional status are independent predictors of clinical failure after surgical gastrojejunostomy 2
Follow-up Care
- Implement early mobilization as tolerated to prevent complications of immobility 3
- Consider physical therapy consultation for rehabilitation, particularly in patients with prolonged hospital stays 3
- Advance diet carefully, monitoring for signs of delayed gastric emptying or obstruction 2
- For long-term management of patients with gastrojejunostomy after gastric cancer resection, monitor for tumor recurrence which can cause obstruction (reported in approximately 4% of cases) 5