Open Gastrojejunostomy Procedure

Preoperative Preparation

The American Society for Gastrointestinal Endoscopy recommends that patients should be kept nil per os (NPO) past midnight for a procedure the following day, though clear liquids may be provided up to 2 hours before the procedure to reduce aspiration risk 3
Antibiotic prophylaxis with a first-generation cephalosporin or similar agent that covers typical cutaneous organisms should be administered, especially for patients at high risk of infection 3
Coagulation parameters should be optimized before the procedure, with INR less than 1.5 and platelet count greater than 50,000/L 3

The stomach should be mobilized to ensure proper exposure of the anterior gastric wall 4
The gastrostomy should be positioned to the right of midline and lower in the antrum to allow for a shorter, more direct route for the jejunal tube through the pylorus 1, 5
This positioning will minimize gastric looping and help prevent proximal migration of the jejunal component 5
An incision should be made in the anterior wall of the stomach 4

The gastrostomy tube should be inserted through the abdominal wall into the stomach 1, 4
The jejunal extension tube should be advanced through the gastrostomy tube, through the pylorus, and into the jejunum beyond the ligament of Treitz 1, 5
Fluoroscopic guidance should be used to confirm proper positioning of the jejunal extension tube 1, 6
The tube should be secured in place and patency confirmed by injecting contrast material 5

Continuous rather than bolus feeding through the jejunal port is required due to loss of the stomach reservoir 7
Mechanical issues, such as tube kinking or coiling in the stomach, should be monitored 7

In patients with ascites, malnourishment, or steroid treatment, gastropexy sutures are imperative to prevent leakage 4
For patients with upper GI stenosis, image-guided jejunostomy is favored as it prevents the need for endoscope passage 5
Success rates for percutaneous gastrojejunostomy range from 90% to 100%, with similar outcomes between endoscopy-guided and fluoroscopy-guided techniques 5

Tube dislocation or migration can be avoided by cutting the external gastrostomy tube length to shorter than 10 cm and using an extension tube of longer length 1, 6
Gastric looping can be prevented by positioning the gastrostomy to the right of midline and lower in the antrum 1, 5
Difficult jejunal access can be overcome by using a stiff wire or sometimes two wires 1, 5
Infection risk can be prevented by proper antibiotic prophylaxis and aseptic technique 3