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INDICATIONS

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Gastrojejunostomy is indicated for certain patients with duodenal ulcer complicated by pyloric obstruction. It is indicated also if technical difficulties prevent resection or make resection hazardous; if the patient is such a poor operative risk that only the safest surgical procedure should be carried out; or if a vagus nerve resection has been performed. It is occasionally indicated for the relief of pyloric obstruction in the presence of nonresectable malignancies of the stomach, duodenum, or head of the pancreas.

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PREOPERATIVE PREPARATION

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The preoperative preparation must be varied, depending upon the duration and severity of the pyloric obstruction, the degree of secondary anemia, and the protein depletion. Obviously, electrolyte replacement and fluid resuscitation should be completed. Nasogastric suction should be implemented to allow an empty stomach where complete obstruction has occurred and to prevent aspiration with induction of anesthesia. Preoperative antibiotics should be given. Laparoscopy in these high-risk patients should be considered or at least a laparoscopic-assisted procedure allowing identification of the proximal jejunum and an extracorporeal anastomosis.

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ANESTHESIA

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General anesthesia combined with endotracheal intubation is usually satisfactory.

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POSITION

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The patient is placed in a comfortable supine position with the feet at least a foot lower than the head. In patients with an unusually high stomach, a more upright position may be of assistance. The optimum position can be obtained after the abdomen is opened and the exact location of the stomach is determined.

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OPERATIVE PREPARATION

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The lower thorax and abdomen are prepared in the routine manner.

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INCISION AND EXPOSURE

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As a rule, midline epigastric incision is made. The incision is extended upward to the xiphoid or to the costal margin and downward to the umbilicus. With the abdomen opened, a self-retaining retractor may be utilized; but since most of the structures involved in this operation are mobile, it is usually unnecessary to use any great amount of traction for adequate exposure.

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DETAILS OF PROCEDURE

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The stomach and duodenum are visualized and palpated to determine the type and extent of the pathologic lesion present. A short loop of jejunum is utilized for gastrojejunostomy, with the proximal portion anchored to the lesser curvature. The stoma is made on the posterior gastric wall and extends from the lesser to the greater curvature, about two fingers in length. It is located at the most dependent part of the stomach (figure 1a).

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When the gastroenterostomy is performed with vagotomy in the treatment of duodenal ulcer, the location and size of the stoma are very important. In order to ensure adequate drainage of the paralyzed antrum and keep postoperative side effects to a minimum, a small stoma parallel to the greater curvature and near the pylorus is indicated (figure 1b...

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