Overview
Definition:
Jejunal interposition is a reconstructive surgical technique employed after proximal gastrectomy, typically for gastric cancer or benign gastric outlet obstruction, where a segment of the jejunum is used to bridge the defect between the esophagus and the remaining stomach or duodenum.
Indications:
Primary indications include extensive proximal gastric resections (e.g., total gastrectomy or proximal subtotal gastrectomy with involvement of the gastric cardia or fundus), necessitating esophageal reconstruction
It is also considered in cases of failed or complicated previous reconstructions and for certain benign conditions like severe gastric outlet obstruction refractory to conservative management.
Clinical Significance:
This technique aims to restore gastrointestinal continuity, facilitate food passage, and improve post-operative nutritional status
Proper reconstruction is crucial for patient survival, quality of life, and preventing complications like reflux esophagitis, dysphagia, and malnutrition
Understanding its nuances is vital for surgical trainees preparing for DNB and NEET SS examinations.
Diagnostic Approach
History Taking:
Detailed history of presenting symptoms (dysphagia, vomiting, weight loss, epigastric pain), duration, and exacerbating/relieving factors
Previous surgical history, including type of gastric surgery and any complications
Medical comorbidities that might affect surgical risk.
Physical Examination:
General assessment for nutritional status (BMI, muscle wasting)
Abdominal examination for any masses, tenderness, or signs of previous surgery
Evaluation for signs of dehydration or anemia.
Preoperative Investigations:
Upper GI endoscopy with biopsy for histological confirmation of malignancy or other pathology
CT scan of the abdomen and pelvis for staging of malignancy and assessment of resectability
Barium swallow and meal to assess anatomy and luminal patency
Routine blood investigations including CBC, LFTs, RFTs, serum albumin, and nutritional markers
Endoscopic ultrasound (EUS) for local staging, if indicated.
Surgical Management
Indications For Reconstruction:
Extensive proximal gastric resections where direct esophago-gastric or esophago-duodenal anastomosis is not feasible or safe
Reconstruction is essential for maintaining alimentary tract continuity and function.
Types Of Jejunal Interposition:
Several variations exist, including trans-gastric jejunal interposition (Bridger-type), retro-gastric jejunal interposition, and esophago-jejunal anastomosis with a jejunal pouch (e.g., Roux-en-Y reconstruction, though typically jejunal interposition refers to a more direct bridging segment)
The choice depends on the extent of gastrectomy and surgeon preference.
Procedure Steps:
Following proximal gastrectomy, a segment of jejunum (typically 20-30 cm) is mobilized
This segment is then anastomosed proximally to the esophagus and distally to the remaining stomach (if present) or duodenum
Care is taken to ensure adequate length, good blood supply, and tension-free anastomoses
Preservation of vagal nerve branches is considered where possible
Entero-enteric anastomosis is performed to restore bowel continuity.
Surgical Technique Pearls:
Meticulous handling of the jejunal segment to preserve its vascular pedicle
Ensuring adequate length to avoid tension on anastomoses
Careful selection of the distal anastomosis site to prevent bile reflux or dumping
Prophylactic feeding jejunostomy insertion for early post-operative nutritional support.
Postoperative Care
Initial Management:
Close monitoring of vital signs, fluid balance, and urine output
Nasogastric tube decompression if used
Pain management with appropriate analgesics.
Nutritional Support:
Early initiation of enteral feeding, typically via a feeding jejunostomy tube, once bowel sounds return and there is no evidence of anastomotic leak
Gradual progression to oral diet as tolerated, focusing on small, frequent meals
Nutritional supplements may be required.
Monitoring For Complications:
Vigilant monitoring for signs of anastomotic leak (fever, tachycardia, abdominal pain, peritonitis), bleeding, ileus, and pulmonary complications
Regular assessment of wound healing.
Complications
Early Complications:
Anastomotic leak: A serious complication leading to sepsis and potentially requiring re-operation
Intra-abdominal abscess
Hemorrhage from anastomoses
Wound infection
Pulmonary embolism
Ileus.
Late Complications:
Dumping syndrome (early and late): Characterized by gastrointestinal and vasomotor symptoms post-meal
Gastric stasis or obstruction proximal to the anastomosis
Jejunal stricture or stenosis
Reflux esophagitis
Nutritional deficiencies (e.g., B12 deficiency, iron deficiency anemia)
Weight loss
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique, ensuring tension-free anastomoses and adequate blood supply
Careful patient selection and pre-operative optimization
Prophylactic antibiotics
Early post-operative feeding
Close follow-up and prompt management of any suspected complications.
Prognosis
Factors Affecting Prognosis:
The underlying pathology (e.g., stage of gastric cancer), extent of resection, the patient's overall health status, and the occurrence and management of post-operative complications significantly influence prognosis.
Outcomes With Reconstruction:
Successful jejunal interposition restores digestive continuity, allowing patients to resume oral intake and improve nutritional status
Long-term outcomes are generally favorable with adequate reconstruction and management of post-operative issues, but can be impacted by the primary disease.
Long Term Follow Up:
Regular follow-up appointments are essential to monitor for nutritional status, manage dumping syndrome and other long-term complications, and for oncological surveillance if the gastrectomy was for malignancy
Endoscopic surveillance of the reconstructed pathway may be indicated.
Key Points
Exam Focus:
Understand the indications for jejunal interposition vs
other reconstruction methods like Roux-en-Y
Be aware of the typical length of jejunal segment used and the common sites for anastomosis
Crucial to recall potential early and late complications and their management.
Clinical Pearls:
A tension-free anastomosis is paramount
Preserving adequate jejunal vascularity is critical for graft viability
Early enteral feeding via feeding jejunostomy is often a cornerstone of successful post-operative recovery
Differentiate jejunal interposition from other antecolic/retrocolic reconstructions.
Common Mistakes:
Inadequate jejunal length leading to tension
Compromising jejunal blood supply
Insufficient decompression of the stomach or duodenum post-operatively
Delayed diagnosis and management of anastomotic leaks or jejunal strictures
Failure to adequately address nutritional deficits.