What are the considerations and management strategies for an adult patient with a severe gastrointestinal condition, such as gastric cancer or peptic ulcer disease, undergoing laparotomy and gastrojejunostomy?

Laparotomy and Gastrojejunostomy: Management Considerations

Primary Indication and Patient Selection

For patients with gastric outlet obstruction (GOO) from malignancy who have a life expectancy greater than 2 months, good functional status, and are surgically fit, surgical gastrojejunostomy should be performed. 1

Key Selection Criteria:

• Life expectancy >2 months is the critical threshold for surgical gastrojejunostomy over endoscopic stenting 1
• Poor nutritional status, ascites, and poor functional status are independent predictors of clinical failure and should prompt consideration of alternative approaches 1
• Patients must have adequate gastrointestinal function to absorb and tolerate enteral feeding 1

Surgical Approach

A laparoscopic approach is strongly favored over open laparotomy for gastrojejunostomy due to significantly lower blood loss and shorter hospital stay. 1

Technical Advantages of Laparoscopic Gastrojejunostomy:

• Reduced operative morbidity with mean operating times of 100-113 minutes 2
• Earlier recovery with time to oral intake of 8.5 days vs 12.5 days for open surgery 2
• Lower pain medication requirements (430mg vs 540mg) 2
• Less immune suppression with significantly lower TNF-alpha and IL-6 levels compared to open surgery 2
• Success rate of 96% with conversion to open surgery rarely needed 2, 3

Surgical Technique Considerations:

• Side-to-side gastrojejunostomy is the standard configuration 2
• Antecolic approach is most commonly performed, though retrocolic is acceptable 2
• Major complication rate is approximately 8% including bleeding, wound infection, and failed placement 3

Management in Gastric Cancer Context

For Resectable Gastric Cancer:

• Adequate gastric resection to achieve negative microscopic margins (typically 4cm from gross tumor) with regional lymphadenectomy examining ≥15 lymph nodes 1
• Consider placing feeding jejunostomy tube in select patients, especially if postoperative chemoradiation is likely 1

For Unresectable/Palliative Cases:

• Palliative gastric resection should NOT be performed unless the patient is symptomatic 1
• Gastric bypass with gastrojejunostomy to the proximal stomach is useful for palliating obstructive symptoms in symptomatic patients 1
• Lymph node dissection is not required in palliative procedures 1

Alternative Approaches When Surgery Not Feasible

For patients who are not candidates for surgical gastrojejunostomy, enteral stent placement should be considered. 1

Contraindications to Enteral Stenting:

• Multiple luminal obstructions - stents provide limited benefit 1
• Severely impaired gastric motility - stents ineffective 1
• In these scenarios, venting gastrostomy should be considered 1

EUS-Guided Gastroenterostomy:

• Technical success rate of 92% with clinical success of 90% 1
• Lower re-intervention rates compared to enteral stents 1
• Requires experienced endoscopist and currently lacks FDA-approved dedicated devices 1

Feeding Jejunostomy Considerations

Indications for Jejunostomy Tube Placement:

• Risk of gastroesophageal reflux - jejunal feeding eliminates but does not completely prevent reflux risk 1, 3
• Early postoperative feeding in major upper GI surgery 1, 4
• Prolonged fasting periods or hypercatabolic states 4
• Patients requiring subsequent chemotherapy or radiotherapy 4

Technical Approach:

• Laparoscopic needle catheter jejunostomy is safe and effective with mean operating time of 51 minutes 5
• Witzel longitudinal technique has technical complication rate of 2.1% 4
• Enteral nutrition can be initiated on postoperative day 1 after fluoroscopic confirmation 5
• Complications include tube dislocation (most common), obstruction, and infection with rates of 1.5-6.6% depending on technique 4

Critical Perioperative Management

Mandatory Diagnostic Considerations:

• All gastric ulcers must be biopsied to exclude malignancy, as 10-16% of gastric perforations are caused by gastric carcinoma 1, 6
• Symptomatic response to PPI therapy does not preclude gastric malignancy - additional diagnostic testing required 7
• Endoscopy should be considered in older patients with suboptimal response to treatment 7

Management of Perforated Peptic Ulcer:

• Primary suture with omental patch is recommended for perforations <1cm in hemodynamically stable patients 1
• Laparoscopic approach is associated with decreased operative time, blood loss, and length of stay 1
• Biopsies of perforated ulceration are mandatory to exclude malignancy 1

Common Pitfalls to Avoid

• Performing palliative gastric resection in asymptomatic patients - this increases morbidity without benefit 1
• Selecting surgical gastrojejunostomy for patients with life expectancy <2 months - endoscopic stenting provides faster relief with acceptable re-intervention rates 1
• Using open approach when laparoscopic expertise available - this increases blood loss, hospital stay, and immune suppression 1, 2
• Placing enteral stents in patients with multiple obstructions or gastric dysmotility - these will fail and require conversion to venting gastrostomy 1
• Failing to biopsy gastric lesions - up to 16% of gastric perforations are malignant 1, 6
• Removing gastrostomy tubes before 14 days - this risks intraperitoneal leakage before fibrous tract establishment 1