Meridian Surgical Specialists – Puyallup, Washington
Informed Consent – Gastrojejunostomy
Your doctor has determined that you have an abnormality in your stomach or intestine which requires a
surgical procedure called a gastrojejunostomy.
Description of the Procedure
The operation you and your doctor are considering involves a surgical cut in the belly and stomach. In the
course of this operation, the doctor attaches the stomach to the intestine in an effort to allow the stomach to
drain more easily. Generally, this surgery is done on people who have “peptic ulcer disease”, or “stomach
blockage”. Although complications from this operation are not common, they do occur. It is possible that
this operation will not help you; it is even possible that you will be worse after the operation than you are
right now. Because of these facts, your doctor can make no guarantee as to the results or benefits that might
be obtained from this operation.
Procedures That May be Done at the Same Time
1. Feeding Tube Placement- to allow intestinal use and nutrition while stomach is at rest.
2. Cholecystojejunostomy- drainage of bile system into intestines if tumor is blocking the bile tubes.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and
those that are specific for a gastrojejunostomy. In any medical treatment, it is impossible to predict all the
things that could go wrong. Fortunately, complications are the exception rather than the rule. Every
reasonable effort is made to avoid complications. The most common possible complications are as follows :
Possible complications of any operation:
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion is rare.
2. Infection – we take special care to prevent an infection, but it is always a possibility.
3. Reactions to medications – this could be many things, from a minor rash to possible death.
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
Possible complications following gastrojejunostomy:
1. Slow stomach emptying- one to two weeks of hospitalization with an empty stomach may be required.
Nausea, full feeling, heartburn, and weight loss are common initially, but slowly improve.
2. Leaking anastamosis- if the new stomach emptying site leaks, an infection results, prompting surgery
or prolonged external feedings to promote healing.
3. Chronic diarrhea, chronic indigestion, malnutrition, hernia at the incision site, and pneumonia.
4. Injury to bowel or other internal organs – an injury to a portion of the bowel or other intraabdominal to repair the injury. This may require opening your abdomen to determine the problem.
5. Poor overall condition of patients undergoing this procedure brings increased risk of wound healing,
respiratory difficulties, infection, etc.
(see other side)
Consent for Treatment
I understand my need for a gastrojejunostomy. I have read and understand the above explanation of
the operation being proposed. My surgeon has answered my questions, and I choose to proceed with
surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving a gastrojejunostomy will benefit from the operation, I
may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
____ I waive the right to read this form, and do not want to be educated and informed of treatment
risks; nonetheless, I understand the need for this surgery and grant permission to the surgeon to
proceed on my behalf.
SIGNATURE _____________________________________________________ DATE _________________
10/04 pjd