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142 Atlas of Gastrointestinal Surgery: The Stomach
Scope
Internal bolster
Dilator
External bolster
Internal
bolster
Gastrostomy
tube
11
The gastroscope is then reintroduced into the stomach, and the
position of the catheter is inspected. An external bolster (12) is insert-
ed over the portion of the gastrostomy tube that exits through the
abdominal wall, and is sutured in place. The dilator portion of the
catheter is trimmed away, and the feeding adapter is
attached (11). The inner bolster should be
inspected and found to lie directly against
Abdominal
wall
Gastrostomy
tube
Gastrostomy tube
External bolster
12
the gastric mucosa without blanching of
the mucosa (12, 13). Excessive ten-
sion should be avoided between the
inner and outer bolsters (13)
because it may produce ischemia of
the intervening tissue with subse-
quent necrosis, infection, or prema-
ture extrusion of the tube.
Liver
Esophagus
Internal
bolster
Gastric lumen
Pancreas
Colon
13
Blade
Needle
Fascia
Percutaneous Endoscopic Gastrostomy 143
“Introducer” Technique
The preparation of the patient and selection of the gastros-
tomy site are performed as described for the “push” tech-
nique. In this method the endoscopist serves only as an
observer and guides the placement of the catheter. Needle
puncture is performed at the chosen site, as in the “push”
method. After the needle has entered the gastric lumen, a
knife blade is used to divide the fascia for subsequent pas-
sage of the dilator (1). A flexible guidewire is inserted
through the needle into the stomach (2). Once the wire is
Gastric lumen
well within the lumen, the needle is removed, leaving only
1
Flexible
guidewire
inserted
the wire in the stomach (2).
Needle
removed
2
144 Atlas of Gastrointestinal Surgery: The Stomach
Gastric
lumen
Dilators
passed
over
guidewire
Abdominal wall
Guidewire
Next, a series of dilators are passed over
the guidewire and directed in a perpen-
dicular direction into the gastric lumen
(3). The endoscopist should take care to
visualize the passage of each dilator well
into the gastric lumen (4).
Dilator
Gastric
lumen
Scope
Progressively larger dilators (12F, 14F) are passed (5), until
finally, after the size of the tract has been enlarged, a 17F
introducer with a special outer, peel-away sheath (6) is passed
over the quidewire into the gastric lumen. These maneuvers
may require some force and often a twisting motion.
4
3
Larger
dilator
Peel-away
sheath
over
largest
dilator
5 6
Guidewire
Percutaneous Endoscopic Gastrostomy 145
Dilator
Scope
Sheath
It is important that the endoscopist visualize
both the introducer and the outer sheath with-
in the stomach (7, 8). The introducing
8
guidewire and the 17F dilator are then
withdrawn, leaving only the peel-away
sheath in the stomach (9). A 14F,
lubricated, balloon catheter is then
passed through the peel-away sheath
into the stomach (10).
Dilator
7
Dilator
withdrawn
9
Balloon
catheter
inserted
10
Sheath
146 Atlas of Gastrointestinal Surgery: The Stomach
Sheath
Scope
Balloon
Catheter
Sheath
The balloon is inflated with saline, and the
outer sheath is peeled away (11, 12).
Traction is then applied to the catheter
until the balloon tip meets the gastric
12
mucosa (13). The balloon approximation to
the gastric wall should be viewed endoscopically
to ensure that excessive tension is not placed against
the gastric mucosa (14). The catheter should be secured
into position with a suture. In most cases after PEG, the
11
tube is initially placed to dependent drainage. Feeding can
usually be started within 24 hours.
Catheter
Suture
14
Gastric
mucosa
13
REMEDIAL OPERATIONS FOLLOWING
GASTRIC SURGERY
Operative Indications
Following gastric surgery, individuals are vulnerable to a variety of long-term morbidity, loosely grouped together as the
postgastrectomy syndromes. These complications are seen as substantial and persistent problems in perhaps 5 to 10% of
patients who undergo gastric surgery. Some of the complications are attributed to gastric resection, whereas others are prob-
ably more related to the loss of the pyloric sphincter. Thus, not only patients who undergo gastric resection, but also those
who undergo a pyloroplasty, a gastrojejunostomy, or a vagotomy are subject to these complications. All of these compli-
cations are now seen only infrequently because of the decrease in gastric surgery owing to a marked decrease in the inci-
dence of peptic ulcer disease and gastric cancer.
The postgastrectomy syndrome includes dumping, which is secondary to the rapid emptying of unmixed high osmolar
contents directly from the stomach into the jejunum. The resulting cramping, diarrhea, and hypoglycemia are secondary to
a cascade of hormonally mediated events, as well as fluid shifts secondary to the high osmotic load in the jejunum. Bile
reflux gastritis is one of the more commonly seen postgastrectomy syndromes. This is thought to be secondary to the reflux
of bile and pancreatic juice into the stomach, following loss of the protective pyloric sphincter. Although virtually every
patient who undergoes gastric surgery subsequently has bile reflux into the stomach, as well as endoscopic and histologic
changes of gastritis, only a small percentage of patients actually develop the clinical symptoms of epigastric pain, nausea,
and bilious vomiting. Diarrhea is common after gastric surgery when a vagotomy is included, but it actually decreases as the
weeks and months pass. A small percentage of patients, however, are left after a year’s period with severe disabling diar-
rhea. The afferent loop syndrome may be seen after a Billroth II gastrojejunostomy. It is secondary to partial obstruction of
the afferent loop, with a resulting backup of pancreatic and biliary secretions in the duodenum until the pressure rises to
the point where the partial obstruction is overcome, with rapid emptying of the afferent loop contents into the stomach.
Vomiting usually is a prominent part of this syndrome. Finally, recurrent ulcer disease at the gastrojejunal or gastroduodenal
anastomosis is seen with a predictable frequency. At times it is difficult to determine whether it is secondary to reflux bile
gastritis and attributable to a postgastrectomy syndrome, or whether it is merely secondary to an inadequate ulcer
operation. All of these syndromes are seen with a much higher frequency in the first weeks and months after surgery than
they are later on. Their prevalence clearly decreases to the point where at 1 year the majority of patients have no
symptoms or have ones that are tolerable without further surgery. A small group of patients are left with symptoms that
require remedial surgery.
Conversion of a Billroth II
Gastrojejunostomy to a Roux-en-Y
Gastrojejunostomy
Operative Indications
The patient demonstrated in this series had previously undergone an antrectomy and truncal vagotomy with a Billroth II gas-
trojejunostomy for chronic duodenal ulcer disease. The patient eventually developed symptoms of nausea and vomiting,
epigastric discomfort, and weight loss. Upper gastrointestinal series performed with barium and upper endoscopy demon-
strated gastritis, ulceration at the gastrojejunostomy, and a markedly dilated afferent jejunal loop. The patient had devel-
oped severe alkaline reflux gastritis; recurrent ulceration at the gastrojejunostomy, either from alkaline reflux or from peptic
ulcer disease; and the gastrojejunostomy had become strictured, resulting in partial obstruction of the afferent loop. It was
decided that resecting the gastrojejunostomy and removing a portion of the remaining gastric pouch and converting to a
Roux-en-Y gastrojejunostomy would eliminate reflux of bilious contents into the stomach, would take care of the partially
obstructed afferent loop, and with the gastric resection and checking for completeness of the vagotomy, would further
ensure against recurrent peptic ulcer disease (insets).
Previous Billroth II
Roux-en-Y
gastrojejunostomy
Operative Technique
The patient is explored through an upper midline
Bile
reflux
Stenotic
gastrojejunostomy
incision. After all adhesions are taken down, the
esophagus is encircled with a small Penrose drain.
The esophagus and surrounding tissues are careful-
ly examined for residual vagal fibers to be certain
Afferent loop
syndrome
that an incomplete vagotomy is not partially
Conversion of a Billroth II Gastrojejunostomy to a Roux-en-Y Gastrojejunostomy 149
responsible for the ulceration seen at the gastrojejunostomy. When this maneuver
is performed, all small fibers palpated along the esophagus should be divided. In
addition, the retroperitoneum behind the esophagus, between the two crura of the
Esophagus
Divided
vagus nerves
(prior vagotomy)
Duodenal
stamp
Liver
Stomach
Jejunum
Colon
Omentum
1
Lesser
curvature
cleaned
Stomach
Jejunum
Greater
curvature
cleaned
2
diaphragm, has to be carefully examined for an
overlooked posterior trunk (1). The afferent and
efferent limbs are dissected free, and the omentum
is removed from the greater curvature. The lesser
curvature is also cleaned in preparation for resect-
ing a portion of the residual gastric pouch (2).
150 Atlas of Gastrointestinal Surgery: The Stomach
Approximately one-fourth to one-third of the residual gastric pouch, along with the gastrojejunostomy, is resected. The
stomach is divided with two or three firings of the GIA stapler. The mesentery to the loop of jejunum comprising the gas-
trojejunostomy is doubly clamped with Kelly clamps, divided, and ligated with 2-0 silks (3).
Esophagus
Duodenum
GIA stapler
Stomach
Prior
gastro-
jejunostomy
Jejunum
Colon
Efferent limb
of jejunum
Enlarged
afferent limb
of jejunum
Mesentery
3
Stomach
Conversion of a Billroth II Gastrojejunostomy to a Roux-en-Y Gastrojejunostomy 151
A Roux-en-Y loop is constructed by bringing up the jejunum
just beyond the original gastrojejunostomy. The stapled end is
inverted with a layer of 3-0 silk Lembert sutures. Because
the anastomosis was initially done in an antecolic fashion,
all of these maneuvers are easily accomplished. The Roux-
en-Y loop is also brought up in an antecolic fashion. The
Outer layer
of posterior row
Jejunum
Staple line
resected
lesser curvature of the stomach, which had been stapled,
is inverted with a layer of interrupted 3-0 silk Lembert
sutures. A gastrojejunostomy to the Roux-en-Y loop is con-
structed along the greater curvature of the stomach. This is
performed in two layers. The outer posterior row con-
sists of an interrupted layer of 3-0 silk Lembert
sutures. The gastric staple line is excised and a
jejunostomy is performed, both with the elec-
trocautery (4). The inner layer of the pos-
terior row consists of a continuous locking
stitch of 3-0 synthetic absorbable material
4
(5), brought around anteriorly as the inner
layer of the anterior row, using a Connell stitch (6).
Inner layer
of posterior row
5
Inner layer
of anterior row
6
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