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.
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.
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.
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.
