Chapter 36: Roux-en-Y Gastrojejunostomy

INDICATIONS

The diversion of bile away from the gastric outlet that has been altered by pyloroplasty or some type of gastric resection may be indicated in an occasional patient with persistent and severe symptomatic bile gastritis.

PREOPERATIVE PREPARATION

A firm diagnosis of postoperative reflux gastritis should be established. Endoscopic studies should demonstrate gross as well as microscopic evidence of severe gastritis of greater intensity than is routinely observed from the regurgitation of duodenal contents through an altered gastric outlet. A gastric analysis is performed in a search for evidence of previous complete vagotomy. Barium studies and serum gastrin determinations are routinely performed. In addition to a firm clinical diagnosis of postoperative reflux bile gastritis, there should be evidence of persistent symptoms despite long-term intensive medical therapy. The operative procedure is designed to completely divert the duodenal contents away from the gastric outlet. Ulceration will occur unless the gastric acidity is controlled by a complete vagotomy combined with antrectomy. Constant gastric suction by a nasogastric tube is maintained.

ANESTHESIA

General anesthesia combined with endotracheal intubation is satisfactory.

POSITION

The patient is placed in a supine position with the feet lower than the head.

OPERATIVE PREPARATION

The skin of the lower thorax and abdomen is prepared in a routine manner. Then a time-out is performed.

INCISION AND EXPOSURE

The incision is made through the scar of the previous gastric procedure. The incision should extend up over the xiphoid because exploration of the esophagogastric junction may be required to determine the adequacy of a previous vagotomy. Care is taken to avoid accidental opening of loops of intestine that may be adherent to the peritoneum.

Even when a previous vagotomy has been performed, it is advisable to search for overlooked vagal fibers, especially the posterior vagus nerves, unless firm adhesions between the undersurface of the left lobe of the liver and upper stomach make such a search too hazardous. The site of the previous anastomosis is freed up to permit careful inspection and palpation for evidence of ulceration or stenosis or evidence of a previous unphysiologic procedure such as a long loop, angulation, or partial obstruction of the jejunostomy. A patulous gastroduodenostomy may be found (FIGURE 1).

The extent of the previous resection must be determined to be certain that the antrum has been resected. A complete vagotomy as well as antrectomy is mandatory as a safeguard against recurrent ulceration.

DETAILS OF THE PROCEDURE

When a Billroth I procedure is to be converted, it is essential to carefully isolate the anastomosis both anteriorly and posteriorly before applying straight Kocher clamps to either side of the anastomosis (FIGURE 2). ...