Gastrojejunostomy

Overview of Gastrojejunostomy

A gastrojejunostomy is a type of surgery that connects the stomach to the jejunum, a part of the small intestine. This can be done either with sewing by hand or using a medical stapler, and it can be performed as an open surgery or a minimally invasive one called laparoscopy. In some cases, this procedure can be done using an endoscope, which is a long, flexible tube that helps doctors see inside your body.

There are different reasons for doing this surgery. It can be used to go around a blockage, as part of a weight-loss method, or a process to rebuild the stomach after part of it has been removed. The first successful operation of this type was carried out by Anton Woelfer in 1881 to bypass a stomach cancer.

A specific type of gastrojejunostomy, known as the Billroth II procedure, involves attaching the stomach to the jejunum without creating a special path for digestive juices from the pancreas and the gallbladder. This procedure got its name from Dr. Theodor Bilroth, Woelfer’s mentor, even though Bilroth didn’t successfully do his first gastrojejunostomy until 1885.

As for the Roux-en-Y procedure, it’s a type of gastrojejunostomy that connects the part of the stomach left after surgery to one part of the jejunum, and then a separate connection is made further down the jejunum. This was popularized by Cesar Roux in 1887, even though the first procedure of this kind was done by Woelfer in 1883.

Anatomy and Physiology of Gastrojejunostomy

The stomach is a vital organ located in the upper-left area of the abdomen. It is connected to the esophagus, which delivers food to the stomach. The start of the stomach is called the cardia, which extends to create the main body of the stomach and the top bit, known as the fundus. Following this is the antrum and the pylorus, which is connected to the duodenum (the first part of the small intestine). Different parts of the stomach are associated with other structures: the greater omentum hangs down from the stomach, while the lesser omentum connects the stomach and the liver.

The stomach gets a lot of blood supply from branches of the celiac trunk, and also can get blood from superior mesenteric artery through gastroduodenal arteries. The veins of the stomach directs blood back to different veins like the portal vein, splenic vein, and superior mesenteric vein. The stomach is connected to the brain by the right and left vagus nerves and also drains excess fluid through a lymphatic system. The stomach’s location close to many important organs means that surgeons must be extensively trained and knowledgeable about these parts before operating on the stomach.

The function of the stomach is to process and digest food. This involves several hormones and nerve signals that control the stomach’s movement and acid production. A significant function includes the production of the hormone gastrin by the G cells; this hormone increases the production of stomach acid. Also, the stomach turns food into chyme, which is rich in nutrients and is further broken down in the duodenum. If the normal digestion process is altered too much, it can lead to health problems like ulcers and something called “dumping syndrome”.

The jejunum is the middle section of the small intestine that lies between the duodenum and the ileum. It is approximately 250 cm long and starts at the ligament of Trietz. The jejunum gets its blood supply from the superior mesenteric artery and drains blood through superior mesenteric vein. Essentially, its role is to absorb most nutrients and vitamins from the food, except for iron and vitamin B12, which are absorbed in the duodenum and terminal ileum, respectively. The jejunum has long extensions called villi, which increases its surface area for absorption. The movement of the jejunum is controlled by nerve stimuli and the hormone called motilin.

Why do People Need Gastrojejunostomy

A gastrojejunostomy is a surgical procedure that a doctor might recommend in certain situations. It involves creating a new connection between your stomach and a part of your small intestine, called the jejunum.

Here are the main reasons why a doctor might do this surgery:

First, it could be a way to get around an obstacle in the lower part of your stomach or at the beginning of your small intestine. This blockage could be a result of cancer or scarring from an ulcer or another issue. By creating a new pathway, food can bypass the blocked area.

Second, this surgical procedure can be used as part of a weight-loss strategy. This is the case when a specific type of gastrojejunostomy, known as a Roux-en-Y procedure, is performed. This surgery makes your stomach smaller and allows food to bypass a portion of your small intestine so you absorb fewer calories.

Third, a gastrojejunostomy might be performed as a part of a reconstruction procedure after part of the stomach has been removed due to cancer. The goal in this case is to reestablish a normal pathway for food after the surgery.

When a Person Should Avoid Gastrojejunostomy

A gastrojejunostomy is a surgical procedure that might not be performed if it would be too risky for the patient or if there is a high chance of a leak at the site where the stomach and small intestine are connected, known as an anastomotic leak.

This operation might not be safe for people who have severe scar tissue (called adhesions), fluid buildup in the abdominal cavity (known as massive ascites), widely spread cancer in the abdomen (termed abdominal carcinomatosis), swollen veins in the stomach (extensive gastric varices), or a significant change in body structure due to previous surgeries. The final decision on whether to go ahead with the operation is left to the treating surgeon, who has to weigh the risks and potential complications.

A high risk of an anastomotic leak often happens in patients who are malnourished, especially those with stomach cancer or ulcers. If a patient needing a gastrojejunostomy shows signs of malnutrition, their nutritional status should be checked. If the tests indicate malnutrition, then they should be given food through a feeding tube or directly into their veins (parenteral or enteral nutrition) to improve their nutritional status before the surgery can take place.

Equipment used for Gastrojejunostomy

If the doctor plans to perform a gastrojejunostomy (a surgical procedure connecting the stomach and the jejunum, which is part of the small intestine) using a method called laparoscopy (surgery performed through small cuts using a camera), they will need specific tools and equipment, including:

• A nasogastric or orogastric tube, which goes through the nose or mouth into the stomach to remove fluids or gases
• A liver retractor, a tool to gently move the liver to the side and give the doctor a better view
• A laparoscope, a special camera with a light, attached to a monitor so the doctor can see inside the body
• Insufflation equipment, which is used to pump gas into the body to create more space to operate
• Laparoscopic trocars, sharp instruments used to make the holes for the laparoscope and other tools
• Bowel graspers, tools to gently hold and manipulate the bowel during surgery
• Harmonic scalpel or Ligasure, devices that cut tissue and seal blood vessels
• Electrocautery equipment, which uses electric current to stop bleeding
• Laparoscopic suction irrigator, a device that combines suction and fluid delivery to clean the area during surgery
• Laparoscopic linear cutting stapler or end-to-end anastomotic stapler, depending on the planned technique. These tools are used to create a secure connection between different parts of the digestive tract
• An esophagogastroduodenal scope, a flexible tube with a camera used to inspect the esophagus, stomach, and the first part of the small intestine

If the gastrojejunostomy is to be performed using an open surgery method (larger incision), then the following equipment will be required:

• A nasogastric or orogastric tube
• A liver retractor
• Bowel clamps, used to temporarily close off parts of the intestine during surgery
• Bowel forceps, similar to graspers but used in open surgery
• Harmonic scalpel or Ligasure
• Electrocautery equipment
• A regular suction irrigator
• A linear cutting stapler, end-to-end anastomotic stapler, or appropriate suture, depending on the type of technique planned for the surgery
• A needle driver, a tool used for suturing, or sewing up incisions or wounds
• An esophagogastroduodenal scope

Who is needed to perform Gastrojejunostomy?

A gastrojejunostomy is a type of surgery that’s carried out by a team of healthcare professionals in an operating room. This team consists of a main surgeon, an assistant surgeon, a scrub tech (a person who assists in surgical operations), an anesthesiologist (a doctor who manages pain or puts patients to sleep during surgery), and a circulating nurse (a nurse who makes sure the operating room runs smoothly).

Extra staff may be needed to help with patient care before and after the surgery. Exactly who these extra people are can vary – it depends on why the surgery is being done in the first place. These extra staff members can include a gastroenterologist (a doctor who specializes in digestive system diseases), an oncologist (a doctor who treats cancer), a dietician (a health professional who helps patients with dietary needs), a psychiatrist (a doctor who treats mental health issues), a pharmacist, ICU or floor nurses, and a discharge planner (someone who helps plan what happens after you leave the hospital).

Preparing for Gastrojejunostomy

The steps doctors take before doing a procedure called a gastrojejunostomy, where they make a connection between the stomach and small intestine, depend on the reason for the operation.

If the surgery is performed after removing cancer (a procedure known as resection of malignancy), the patient might have to undergo treatments to kill the cancer cells (neoadjuvant chemotherapy), get help for proper nutrition, and form a future care plan with a cancer team.

If the surgery is done to reroute the food’s pathway around a blockage, like say from an ulcer, doctors first make sure the patient is well-nourished. This might involve getting advice from a nutrition specialist, starting intravenous nutrition (feeding by injecting nutrients directly into the blood), or placing a food tube farther down the digestive tract.

If the procedure is being done to help with weight loss, the patient will need a full bariatric work-up. This includes seeing a dietitian to set a pre-surgery weight loss plan, possibly seeing a mental health professional for evaluation, and bringing other health risks such as blood sugar and blood pressure under control.

How is Gastrojejunostomy performed

A gastrojejunostomy is a type of surgery that might be done if there’s something blocking the lower part of your stomach. Here is a simplified version of how doctors perform this surgery:

Step 1: Access the Belly
First, you’ll be positioned flat on your back with your arms stretched out to the sides. They’ll use a tube through your nose or mouth to empty your stomach. Then the surgeon will make a cut from just below your chest (where the breastbone ends) to your belly button. This cut might be made bigger if they need to see more of your belly. If they are doing a type of surgery called ‘laparoscopic’, they’ll make a couple of small cuts and use special tools to do the surgery. Once they’ve made the cuts, they’ll move your liver to the side a bit, whether they’re doing the surgery the regular way or with the special tools.

Step 2: The Right Place for the Stomach Opening
The doctors will choose a spot on your stomach that’s about an inch or two away from the blockage. They won’t pick a spot high up on the stomach because that could lead to problems with bile (a liquid made by your liver) flowing back into your stomach and might slow down your digestion.

Step 3: Bringing the Jejunum to the Stomach
Next, they’ll choose a part of your small intestine (called the jejunum) that’s about 4 to 6 inches or so away from where it connects to another part of your intestines (this connection point is known as the ligament of Trietz). They’ll bring this small part of the intestine up to the place they’ve picked on your stomach and make sure it’s not too tight or stretched out. Then, with special stitches that dissolve over time, they’ll connect the jejunum to the stomach.

Step 4: Making the Openings
The surgeon will then make an opening in both your stomach and jejunum. This opening will be made next to where they put the stitches in step 3, and will be about 2 inches long. They’ll be ready to suction away any stomach or intestine contents that might leak out.

Step 5: Connecting the Two
Next, they’ll sew the openings of your stomach and jejunum together using stitches that dissolve over time. They’ll finish by going over the stitches again to make them stronger.

Step 6: Checking for Leaks
The doctor will look at the spot where your stomach and intestine were sewn together to make sure there’s no bleeding. They’ll then fill your stomach with water and use a special camera to check for any leaks.

There’s another way to do this surgery using a special stapler instead of stitches. After the surgery, you’ll probably stay in the hospital for a while. You’ll start eating and drinking slowly, beginning with clear liquids. You might need to have some fluids into your vein until you’re drinking enough on your own.

Possible Complications of Gastrojejunostomy

Gastrojejunostomy, a type of stomach surgery, can come with several possible complications like:

Feeling Sick or Excessive Vomiting: After this operation, some people feel nauseous or might vomit. This usually gets better with some help from your doctor. However, if it continues, it might suggest that there’s a problem inside the body like possible bowel obstruction, which is when your intestines get blocked.

Bleeding: Like any other operation, there’s always a chance of bleeding. This can vary from a slight bleed that gets better on its own, to a heavy bleed that might need another operation.

Deep Vein Thrombosis and Blood Clots: This is a situation where a clot forms in a vein, usually in your leg, which can be harmful. To reduce this risk, doctors usually give medicine to thin the blood until you’re able to move around again.

Anastomotic Leak: This is a serious complication where the new connection in the stomach leaks. This usually occurs around the third to fifth day after the procedure. If you notice symptoms like fast heart rate and stomach pain, it’s important to get checked right away for a possible leak.

Bowel Obstruction: This surgery can also result in a blockage in the bowel, either due to a surgical mistake (like the bowel getting twisted) or other issues such as scar tissue. While it’s possible to wait and see if it resolves on its own, a long-lasting blockage may require another operation.

Internal Herniation: This is when a part of your bowel pushes through a surgical opening in your stomach wall. This can be an emergency, as it can lead to bowel strangulation, a severe condition where blood flow to your bowel is cut off.

Nutritional Deficiencies: After the surgery, your body might not be able to absorb enough nutrients from your food, which can leave you malnourished. Additionally, depending on what part of your bowel is bypassed, certain specific nutrients might not be absorbed well.

Dumping Syndrome: This happens when food moves too quickly from your stomach into your small intestine. To prevent this, it’s recommended to eat multiple small meals throughout the day instead of larger ones.

Marginal Ulcer: After surgery, you may develop a sore in the small intestine near the stomach, because this part doesn’t have the same protective measures against stomach acid like other parts of the intestine.

Bile Reflux: This is when the bile, a digestive fluid, moves from your small intestine back into your stomach, causing irritation. This can happen because of the new connection between your stomach and small intestine.

What Else Should I Know About Gastrojejunostomy?

Gastrojejunostomy is a surgical procedure that is useful in treating a variety of health conditions, including blockages in the stomach outlet and severe obesity. It’s essential for everyone involved in healthcare, from doctors to nurses to caregivers, to understand this procedure and the possible complications. This knowledge helps to ensure the best possible results for patients.

Patients who have undergone a procedure that includes a gastrojejunostomy may face various complications. Therefore, all healthcare providers caring for these patients should comprehend how the changes made to the body during the surgery can lead to specific health problems. Gastrojejunostomy involves surgically creating a passage between the stomach (gastro-) and the small intestine (jejunum). This alters the natural course of digestion and can occasionally lead to certain issues.