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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 ...

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