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152 Atlas of Gastrointestinal Surgery: The Stomach
The outer layer of the anterior row consists of inter-
rupted 3-0 silk Lembert sutures (7). A 3-0 silk
reinforcing suture is placed at the junction of the
lesser curvature gastric suture line and the gastroje-
junostomy. This suture passes into the stomach on
one side of the gastric suture line and out the other
3-corner
suture
Outer layer
of anterior row
side, parallel to the gastrojejunostomy. On the
jejunum, the suture passes in the opposite direc-
tion, also parallel to the gastrojejunostomy, and
is tied. (inset)
The operative procedure is completed by
anastomosing the dilated proximal jejunum
to the Roux-en-Y jejunal loop approximate-
ly 60 cm from the gastrojejunostomy. This
operative procedure corrects all of the causes
for the patient’s symptoms resulting from the
7
prior gastric surgery. The patient’s gastric remnant
was re-resected and the completeness of the vagoto-
my checked, thus eliminating any possibility for subse-
quent recurrent peptic ulcer disease. In addition, because
of the Roux-en-Y jejunal loop, bilious contents can no longer
reflux up into the stomach causing bile reflux gastritis.
vagus nerves
(prior vagotomy)
Biliary
tree
Conversion of a Billroth II Gastrojejunostomy to a Roux-en-Y Gastrojejunostomy 153
Esophagus
Divided
Stomach
Omentum
Duodenal
stump
Jejunum
Finally because the partially obstructed afferent
loop has now been anastomosed to the jejunum
downstream, the partial obstruction has been
eliminated (8).
Pancreas
Colon
8
End-to-side
jejunojejunostomy
Reversed Jejunal Loop Interposition for
Dumping following Billroth I
Gastroduodenostomy
Operative Indications
Dumping is a complex syndrome that may follow gastric surgery for a variety of etiologies. It is secondary to the rapid
emptying of unmixed food into the duodenum and jejunum, secondary to the loss of the pyloric muscle sphincter. This
results in a cascade of events that leads to hormonal release, as well as fluid shifts secondary to the high osmotic load
dumped into the jejunum. The syndrome consists of abdominal cramping, diarrhea, and often nausea and tachycardia. A
late phase occasionally seen includes hypoglycemia with associated symptoms. The syndrome is frequent initially follow-
ing surgery, but most symptoms disappear or ameliorate by 1 year. Some patients continue to have disabling symptoms.
These patients are candidates for remedial gastric surgery. The most effective operation when this syndrome follows antrec-
tomy, vagotomy, and Billroth I gastroduodenostomy is the interposition of a 10 cm reversed jejunal loop between the
gastric remnant and the duodenum. This, in effect, restores a sphincter mechanism between the stomach and duodenum
and delays gastric emptying.
Operative Technique
The patient is reexplored through an old upper midline incision. The area of the gastroduodenostomy is mobilized, and the
greater and lesser curvatures are cleaned of omentum. The duodenum is mobilized to the proximal second portion. Care
must be taken to avoid injury to the distal bile duct. The old gastroduodenostomy is excised by firing the GIA stapler
across the distal gastric remnant and proximal duodenum (1). The proximal jejunum is then examined and, at a point where
the mesentery has reached its full length, a 10 cm segment is measured. A segment of jejunum is picked with a major ves-
sel arcade, and the mesentery is split down to the root. The 10 cm segment is isolated by firing the GIA stapler proxi-
Reversed Jejunal Loop Interposition for Dumping following Billroth I Gastroduodenostomy 155
mally and distally. The loop of the jejunum is then reversed, by rotating it 180° (1). This can only be accomplished if
the pedicle to the loop of the jejunum can be narrowed down to one major vessel. After the jejunal loop is rotated, it is
brought up through the transverse mesocolon into the upper abdomen (inset).
Divided
Prior
gastro-
duodenostomy
resected
vagus nerves
(prior vagotomy)
GIA
stapler
Esophagus
Stomach
Dudenum
Pancreas
Colon
Mesentery
Jejunum
brought
through
mesocolon
1
Stomach
Colon
10 cm of jejunum
reversed
156 Atlas of Gastrointestinal Surgery: The Stomach
Outer layer
of posterior row
Stomach
Jejunum
A gastrojejunostomy is performed to the distal portion of
the jejunal loop, which has been rotated 180°. A posterior
Jejunostomy
2
row of interrupted 3-0 silk Lembert sutures is placed (2).
The staple lines on the distal stomach and jejunum are excised
with the electrocautery (3).
Staple line
resected
Inner
layer of
posterior row
3
The inner layer of the posterior row of the gastrojejunosto-
my is placed using a continuous locking stitch of 3-0 synthet-
ic absorbable material (4), and is brought around anteriorly
with the Connell stitch (5). The outer layer of the anterior row
consists of interrupted 3-0 silk Lembert sutures. An identical
anastomosis is performed between the other end of the jejunal
segment and the duodenum. This is the proximal end of the
jejunum that has been reversed. The rent in the transverse
mesocolon is loosely sutured to the jejunal pedicle with inter-
rupted 3-0 silk, and end-to-end jejunojejunostomy is per-
formed to restore enteric continuity.
4
Inner
layer of
anterior row
5
Reversed Jejunal Loop Interposition for Dumping following Billroth I Gastroduodenostomy 157
This is performed with an inner continuous layer of
3-0 synthetic absorbable suture material and an outer
layer of 3-0 silk Lembert sutures. The rent in the small
bowel mesentery to the jejunum is closed with inter-
rupted 3-0 silk (6). Care has to be taken not to
make the jejunal loop longer than 10 cm. If the loop
is too long, high-grade partial obstruction of the gas-
tric remnant can occur. In contrast, if the loop is too
short, enough resistance to gastric emptying will not be
achieved to delay gastric emptying.
Duodenum
Esophagus
Stomach
Antiperistaltic
segment of
jejunum
Omentum
Mesocolon
Transverse colon
Mesentery
Mesentery
6
End-to-end
jejunojejunostomy
Reversal of Jejunal Loop for Dumping
following Billroth II Gastrojejunostomy
Operative Indications
Dumping can be seen following pyloroplasty, or gastrojejunostomy, as well as Billroth I gastroduodenostomy. However, it
is seen most frequently following a Billroth II gastrojejunostomy. Most patients who develop postprandial cramping, diar-
rhea, tachycardia, and light-headedness have these symptoms abate as weeks and months pass following their gastric sur-
gery. However, in some patients symptoms persist and become disabling. Such patients are candidates for remedial gastric
surgery. The most effective operative procedure for dumping following a Billroth II gastrojejunostomy is to interpose a
reversed 10 cm loop of jejunum between the gastric remnant and the duodenum. When a patient has had a Billroth II gas-
trojejunostomy, the afferent loop leading to the gastric anastomosis can be used as a reversed jejunal loop (1, 2).
Prior
Bilroth II
1
Anti-
peristaltic
segment of
jejunum
2
Duodenum
Prior
vagotomy
and
gastrojejunostomy
jejunal loop
Reversal of Jejunal Loop for Dumping following Billroth II Gastrojejunostomy 159
Esophagus
Stomach
Efferent
divided
Transverse
colon
Afferent
jejunal loop
3
Operative Technique
The patient is reexplored through a previous upper midline incision. The prior gastrojejunostomy had been performed in an
antecolic fashion, thus making dissection of the afferent and efferent loops, as well as the gastrojejunostomy, relatively sim-
ple. The efferent loop is divided with a GIA stapler, just beyond the gastrojejunostomy. The afferent loop is dissected
free, and 10 cm is very carefully measured retrograde from the gastrojejunostomy and divided with a GIA stapler. To allow
mobility of this 10 cm segment of afferent loop, the mesentery must be contoured carefully to a fairly narrow fulcrum (3).
It is also necessary to dissect out the duodenal stump, because this will be used in the conversion of the Billroth II to a
Billroth I with an interposed reversed jejunal loop. Care must be taken to avoid injury to the distal bile duct.
160 Atlas of Gastrointestinal Surgery: The Stomach
Biliary
tree
Duodenum
Outer
layer of
posterior
4
row
Jejunum
The proximal portion of the afferent loop is then swung
in an antecolic position and anastomosed end-to-end to the
duodenal stump. A posterior outer layer of interrupted 3-0
silk Lembert sutures is placed. The old duodenal stump is
opened with the electrocautery (4). The staple line is
removed from the jejunal loop with the electrocautery.
The inner layer of the posterior row is placed
with a continuous locking stitch of synthetic
absorbable material (5) brought around anteri-
orly with a Connell stitch (6).
Inner layer of
posterior row
5
Inner layer of
anterior row
6
Reversal of Jejunal Loop for Dumping following Billroth II Gastrojejunostomy 161
The outer layer of the anterior row is completed with interrupted 3-0 silk Lembert
sutures (7). Gastrointestinal continuity is reestablished with an end-to-end jejunoje-
junostomy, between the efferent loop and the jejunum just beyond the ligament
of Treitz. This end-to-end jejunojejunostomy is carried out using an inner
continuous layer of 3-0 synthetic absorbable suture material and an
outer layer of interrupted 3-0 silk Lembert sutures. The rent in the
mesentery is closed with interrupted 3-0 silk (inset). The staple
line of the distal afferent loop (d) adjacent to the stomach should
be oversewn with 3-0 silk Lembert sutures. Care has to be taken
in creating the jejunal loop exactly 10 cm in length. If it is longer,
high-grade partial obstruction of the gastric remnant will occur. If
it is too short, it will not present enough resistance to gastric
emptying to act as a sphincter.
Antiperistaltic
segment of
jejunum
Duodenum
Pancreas
Stomach
Omentum
Mesentery
Transverse colon
7
End-to-end
jejunojejunostomy
Jejunum
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