Tricks of the Senior Surgeon

■ When an antecolic gastrojejunostomy is chosen, the afferent jejunal loop can be kept short by placing the transverse colon as much to the right of the gastrojejunostomy as possible.

■ Excessive length of the afferent limb may predispose to "afferent loop syndrome."

■ Inadvertent gastroileostomy is not that uncommon! Make sure, especially when a laparoscopic gastroenterostomy is performed, that the appropriate site of the jejunum is used.

■ Gastric emptying is based on inherent gastric motor function; not on hydraulic pressure gradients. Thus, placing the anastomosis at the "most dependent" portion of the stomach does not have any scientific merit.

■ Place the anastomosis where it lies more comfortably. Provided that there is no kinking, acute angles, or pressure on the efferent and afferent loops, the choice of retrocolic versus antecolic, or distal gastric versus proximal gastric placement of the anastomosis is not so important.

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