Plate 12

Gastrojejunostomy is indicated for certain elderly patients with duodenal ulcer complicated by pyloric obstruction and low acid value. It is indicated also if technical difficulties prevent resection or make it hazardous, if the patient is such a poor operative risk that only the safest possible surgical procedure should be carried out, or if vagus 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. Gastrin levels should be determined.

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. The restoration of blood volume is especially important in patients who have lost considerable weight. Low values of sodium chloride and potassium must be corrected, and the carbon dioxide combining power and blood urea nitrogen returned to normal before operation. Secondary anemia and protein and vitamin deficiencies should be corrected insofar as possible before operation. Their correction aids healing and contributes to the proper emptying of the stomach after operation. The large atonic stomach is emptied by constant gastric suction for several days before operation. The stomach is emptied by gastric lavage, usually the night preceding operation, to make certain that all coarse particles of food have been removed and that gastric tension is relieved. The lavage is repeated 1 to 2 hours before operation. Constant gastric suction with a Levin tube is maintained. Blood must be available for transfusion during the operation.

General anesthesia combined with endotracheal intubation is usually satisfactory. Muscle relaxants may be employed to avoid the deeper planes of anesthesia. Spinal or continuous spinal anesthesia provides profound muscle relaxation and a contracted bowel. Local infiltration is sometimes advisable in poor-risk patients.

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.

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

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.

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 1, A).

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 1, B). The jejunum should be anchored for several centimeters to the gastric wall on either side of the stoma. This permits circular uncut muscles going away from the stoma to contract and improve gastric emptying. Special effort is required as a rule to ensure placement of the stoma within 3 to 5 cm of the pylorus. Because of the fixation of the pylorus associated with duodenal ulceration, it is too impractical to attempt to bring the site of the anastomosis outside the abdominal wall, as shown in the accompanying diagrams.

The location of the stoma is first outlined on the anterior gastric wall with Babcock's forceps. The greater omentum may be brought outside the wound so that the contour of the stomach is not distorted, and the most dependent portion of the greater curvature may be more accurately determined (Figure 2). The Babcock forceps are left in place as the greater omentum is reflected upward over the stomach and the inferior aspect of the mesocolon is visualized (Figure 3). The transverse colon is held firmly by an assistant as the surgeon invaginates the Babcock forceps on the anterior gastric wall. This produces a bulge in the mesentery of the colon at the point through which the stomach is to be drawn (Figure 3). The mesocolon is carefully incised to the left of the middle colic vessels and near the ligament of Treitz, great care being taken to avoid any of the large vessels in the arcade. Four to six guide sutures (sutures a, b, c, d, e, and f) are placed in the margins of the incised mesocolon to be utilized after the anastomosis to the stomach at the proper level. The presenting posterior wall of the stomach is grasped with a Babcock forceps adjacent to the lesser and greater curvatures, and opposite the points of counter pressure from the similarly placed forceps on the anterior gastric wall (Figure 4). A portion of the gastric wall is pulled through the opening. In many instances, the inflammatory reaction associated with the duodenal ulcer may anchor the posterior surface of the antrum to the capsule of the pancreas. Sharp and blunt dissection may be required to mobilize the stomach in order to ensure placement of the stoma sufficiently near the pylorus. Some surgeons prefer to anchor the mesocolon to the stomach at this time. The forceps on the greater curvature is swung toward the operator on the patient's right side, while the forceps on the lesser curvature is rotated to a position opposite the first assistant.

The ligament of Treitz is identified, and a loop of jejunum 10 to 15 cm distal to this fixed point is delivered into the wound. The jejunum at this point is held with Babcock's forceps as the enterostomy clamp is applied. The midsection of the portion of jejunum to be included in the enterostomy clamp may require fixation with thumb forceps to assure an even inclusion of the bowel in the clamp (Figure 5). The clamp should be applied near the mesenteric border, with the handle of the clamp toward the patient's right side and with the proximal jejunal loop in the toe end of the clamp (Figure 5).

Spring clamps are best used without rubber covers because covers make them bulky and so slippery that more pressure is likely to be used than is necessary, especially at either end of the clamp. A clamp of fine spring steel holds its position well without great pressure and leaves no deleterious effects.

With the clamp in position, a piece of gauze is laid next to the jejunum. Then the stomach is grasped in a similar enterostomy clamp, placed with the handle of the clamp toward the patient's head, to include the selected oblique portion of the posterior gastric wall (Figure 6). Now the two enterostomy clamps are bought side to side, so that the distal end of the jejunal opening will be at the greater curvature of the stomach. The portion of the jejunum toward the ligament of Treitz (i.e., the proximal portion) is anchored to the lesser curvature of the stomach (Figure 6). At times, the stomach cannot be sufficiently mobilized for the application of clamps as shown in Figure 6, and the anastomosis is made without a clamp on either side.

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