What are the contraindications for gastrojejunostomy?

Gastrojejunostomy Contraindications

Gastrojejunostomy placement has absolute contraindications including active peritonitis, uncorrectable coagulopathy, bowel ischemia, and mechanical GI obstruction (unless performed specifically for decompression), while relative contraindications include hemodynamic instability, recent GI bleeding, ascites, respiratory compromise, and specific anatomic alterations. 1

Absolute Contraindications

The following conditions absolutely preclude gastrojejunostomy tube placement:

• Active peritonitis - represents an absolute contraindication due to risk of spreading infection and peritoneal contamination 1
• Uncorrectable coagulopathy - must be corrected before proceeding, as gastrojejunostomy is classified as a high-risk bleeding procedure 1
• Bowel ischemia - precludes any enteral access procedure due to risk of perforation and necrosis 1
• Mechanical GI obstruction - is an absolute contraindication unless the gastrojejunostomy is being placed specifically for decompression purposes 1

Relative Contraindications

These conditions require careful assessment but may proceed with appropriate precautions:

Hemodynamic and Bleeding Issues

• Hemodynamic instability - patients must be stabilized before elective gastrojejunostomy placement 1
• Recent GI bleeding from peptic ulcer with visible vessel or esophageal varices - delay procedure for 72 hours due to high rebleeding risk 1
• Bleeding from angiodysplasia, gastritis, or stress gastropathy - carries lower rebleeding risk and does not require procedural delay 1

Anatomic and Structural Issues

• Gastroesophageal reflux disease - represents a relative contraindication for gastrostomy but may actually favor gastrojejunostomy placement 1
• Previous gastric surgery - creates technical challenges but is not an absolute contraindication 1
• Gastric outlet obstruction - is a relative contraindication for feeding gastrostomy but may be an indication for gastrojejunostomy 1
• Colonic interposition between abdominal wall and stomach - makes percutaneous gastrostomy contraindicated, requiring surgical approach if needed 1

Medical Comorbidities

• Ascites - increases risk of peritoneal leak and infection 1
• Respiratory compromise - may worsen with sedation and positioning required for procedure 1
• Extensive gastric ulceration - increases perforation risk 1
• Neoplastic or infiltrative disease of the stomach - may compromise healing and increase complications 1
• Hepatomegaly - can interfere with safe percutaneous access 1
• Gastric varices - pose significant bleeding risk 1
• Late pregnancy - represents relative contraindication due to anatomic and physiologic changes 1
• Peritoneal dialysis - increases infection risk and may compromise dialysis efficacy 1

Disease-Specific Considerations

• Inflammatory bowel disease - particularly Crohn's disease was historically considered a contraindication, but recent evidence suggests gastrojejunostomy can be used when necessary, though it remains a relative contraindication for Roux-en-Y gastric bypass 1
• History of organ transplantation requiring immunosuppression - is a contraindication for Roux-en-Y gastric bypass due to altered absorption concerns 1

Coagulation Parameters for Safe Procedure

Gastrojejunostomy is classified as a high-risk bleeding procedure requiring specific coagulation thresholds 1:

• INR must be corrected to <1.5 before proceeding 1
• Platelet count must be ≥50,000/μL - transfuse if lower 1
• Clopidogrel must be withheld for 5 days before the procedure 1
• Aspirin should NOT be withheld 1
• Therapeutic dose low molecular weight heparin - withhold one dose before procedure 1

Critical Clinical Pitfalls

Poor performance status, elevated C-reactive protein, and prior chemotherapy are independent predictors of poor survival and increased hospital mortality in patients undergoing palliative gastrojejunostomy for malignant obstruction, making patient selection crucial 2. Patients with life expectancy less than 2 months may be better served by endoscopic stent placement rather than surgical gastrojejunostomy 3.