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Gastroenterostomy John Tsiaoussis, Gregory G Gastroenterostomy John Tsiaoussis, Gregory G. Tsiotos Introduction In this chapter both techniques for gastroenterostomy, the open and laparoscopic approaches, are described in patients with gastric outlet obstruction syndrome. Indications and Contraindications Indications ■ Palliation of gastric outlet obstruction caused by advanced gastric, duodenal, or periampullary tumor ■ Gastric drainage following vagotomy when pyloroplasty is not feasible Contraindications ■ Severe hypoalbuminemia ■ Evidence of diffuse metastatic spread, indicating extremely low life expectancy ■ Prohibitive comorbidity Preoperative Investigation/Preparation for the Procedure History: Persistent vomiting Laboratory tests: Electrolytes, albumin, coagulation parameters Radiology: Upper GI contrast study CT scan: Assessment of primary disease/condition Endoscopy: Assessment of gastric outlet obstruction, periampullary biopsy for tissue diagnosis A large-bore nasogastric tube is placed the day prior to the operation for gastric decompression and irrigation. The patient’s water and electrolyte balance are corrected preoperatively. 222 SECTION 2 Esophagus, Stomach and Duodenum Procedure Open, Hand-Sewing Technique Access Midline incision from xiphoid process to the umbilicus STEP 1 Preparation of the jejunal loop using the retrocolic route The gastroepiploic vessels are dissected, clamped, divided and ligated starting about 5cm proximal to the pylorus and moving 6–7cm proximally along the greater curvature of the stomach, so this is completely dissected free from the omentum. The jejunal loop can be brought either anterior to the transverse colon (antecolic), or through a window in the transverse mesocolon (retrocolic).Although a retrocolic gastro- jejunostomy has been considered more prone to obstruction because of its closer proximity to an ever enlarging unresectable periampullary tumor, this has never proved true, espe- cially since patient survival in this context rarely exceeds 6months. On the other hand, the retrocolic route allows more proximal placement of the jejunal stoma and smoother angles between afferent, efferent loops and stomach in both the coronal and the sagittal planes. The window (wide enough to allow comfortable sliding of both afferent and efferent jejunal loops) is made in an avascular plane of the mesocolon left to the middle colic vessels. The ligament of Treitz is identified by lifting up the transverse colon, and the jejunal loop is brought up through the mesocolic window in apposition to the greater curvature (now free from omental vessels). The length of the afferent jejunal limb should not exceed 20cm. The gastrojejunostomy can be placed either on the anterior (easier and thus prefer- able) or the posterior gastric wall; the latter has not proved superior in terms of gastric emptying. Then 3-0 silk traction seromuscular sutures are placed, taking into account that the incision in the jejunum will not be made exactly at the antimesenteric border, but at a level closer to its mesentery on the stomal side. This provides for more com- fortable lining of the completed anastomosis without any undue angles in the transverse plane. At 5-mm intervals 3-0 silk interrupted seromuscular Lembert sutures are placed and tied to create the posterior outer suture line. Two incisions along the gastric and the jejunal apposite segments are then made. Although the gastric incision should be about 4cm, the jejunal incision should be a bit shorter, since it always tends to dilate and ends up being realistically longer than initially planned or thought to be. Gastroenterostomy 223 STEP 2 Technique of anastomosis The posterior full-thickness inner anastomotic layer is made by two 3-0 PDS running sutures in an over-and-over fashion starting at the middle of the posterior layer and moving in opposite directions towards each corner of the anastomosis, where the two corner traction seromuscular stitches are still present. Then, the two 3-0 PDS running suture lines continue into the anterior wall of the gastrojejunostomy (again full-thick- ness) using the Connell technique in order to invert all gastric and jejunal mucosa, which might otherwise protrude out through the anastomosis. Moving from the two corners towards the middle, the sutures meet and are tied together. The anastomosis is completed by placing the anterior seromuscular layer with interrupted 3-0 silk Lembert sutures starting at the corner away from the surgeon and moving towards the surgeon, so that there are no sutures tangling in the middle of the operative field. These outer sutures should be first all placed and then tied; “tying as we go” will lead to packing of the serosa towards the inner suture line and thus placement of each successive suture at an ever increasing distance away from the inner suture line, which may then lead to entrapment of a lot of seromuscular tissue within the suture lines and protrusion of this soft tissue mass towards the anastomosis itself with its potential obliteration. After completion, the anastomosis is brought below the mesocolic window, and the gastric wall (not the jejunal) is tacked circumferentially on the mesocolon with inter- rupted 3-0 Vicryl sutures. A drain tube does not need to be placed. 224 SECTION 2 Esophagus, Stomach and Duodenum Open Stapling Technique STEP 1 Stapling technique The greater curvature is freed from the omentum, the mesocolic window is made and the jejunum and greater curvature are brought to apposition as previously described. Two stab wounds are made with the electrocautery in the greater curvature (12cm from the pylorus) and at the antimesenteric aspect of the jejunum (20cm from the ligament of Treitz). Two Allis clamps, incorporating full thickness gastric and jejunal wall, are placed one each in the gastric and the jejunal stab wounds. The cartridge fork of the GIA-60 stapler is inserted in the gastric lumen and the anvil fork into the jejunal lumen (this move is to push the GIA’s jaws into the lumens, not to pull the stomach and jejunum up towards the stapler). With the help and maneuvering of the two Allis clamps, align equal lengths of gastric and jejunal walls on the forks, keep the jejunal mesentery away from the anastomosis, close the instrument and fire. Open the handle of the stapler slowly and slide it out. Inspect the luminal side of the staple line for possible bleeding. STEP 2 Final reconstruction of the anastomosis The two Allis clamps are now repositioned to grab the two corners of the GIA staple line and the inner (luminal) anastomotic line is inspected for bleeding. Approximate the gastric and jejunal walls with two additional Allis clamps. Slip the jaws of the TA-55 beneath the Allis clamps incorporating all tissue layers as well as the corner end staples of the GIA staple line within the jaws. The corner ends of the two GIA staple lines should be the two corners of the TA staple line, so that these three staple lines (two from the GIA, one from the TA) form a triangle and the wide patency of the anastomosis is secured. Close the instrument and fire. Use a scalpel to excise the protruding tissue along a special groove on the surface of the stapler. Open the instrument to release the tissue and inspect for bleeding. Three single full-thickness 3-0 silk reinforcing sutures are placed at the three corners of the stapled anastomosis, as these represent the theoretically more “vulnerable” points of the anastomosis, since this is where two staple lines meet and overlap. A drain tube does not need to be placed. Gastroenterostomy 225 Laparoscopic Technique STEP 1 Positioning The patient is placed supine. The senior surgeon stands on the patient’s right side and the first assistant on the left. Pneumoperitoneum is established with the Verres needle (by insufflating at a preset pressure of 12–15mmHg), the 0° or 30° laparoscope is intro- duced through a supraumbilical 10-mm port, but it can be moved to other ports as needed intraoperatively. Then, two 10-mm trocars and one 12-mm trocar are inserted in the anterior abdominal wall. The table is tilted at a 30° Trendelenburg position and a Babcock forcep (more atraumatic) is used to bring the omentum and transverse colon cephalad to identify the ligament of Treitz. STEP 2 Preparation of the jejunal loop up to the stomach The first jejunal loop is identified and approximated to the antrum in an antecolic route. If the retrocolic route is chosen, a window in the transverse mesocolon is made using the harmonic scalpel and the jejunal loop is brought up through it. Two 3-0 silk traction sutures are placed (5–6cm from each other) to opposite the jejunum (at a distance of 20cm from the ligament of Treitz) along the greater curvature (at a distance of 5cm from the pylorus). Two stab incisions are made at the approximated gastric and jejunal walls using the Hook device, one opposite to the other. STEP 3 Technique of anastomosis As two graspers are holding the traction sutures on the approximated stomach and jejunum, a 45-mm Endo-GIA stapler is inserted through the 12-mm port. The jaws of the instrument are introduced into the gastric and jejunal lumens. Maneuvering of the suture-holding graspers accommodates stapler insertion. The stapler is closed, fired and eventually removed. The staple line is inspected internally for patency and bleeding. The common gastric and jejunal opening is closed with full-thickness, running 2-0 Vicryl suture tied intracorporeally.Alternatively, an Endo-TA or an Endo-GIA device can be used for closure of the common gastric and jejunal opening. A drain tube does not need to be placed. 226 SECTION 2 Esophagus, Stomach and Duodenum Standard Postoperative Investigations ■ Gastrografin upper GI radiograph (when significant nasogastric tube output persists for longer than a week postoperatively) Postoperative Complications ■ Gastric hemorrhage ■ Anastomotic bleeding ■ Anastomotic leak ■ Obstruction (anastomotic or functional) ■ Anastomotic stenosis (long term) Tricks of the Senior Surgeon ■ When an antecolic gastrojejunostomy is chosen, the afferent jejunal loop can be kept short by placing the transverse colon as much to the right of the gastroje- junostomy as possible.
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