Feeding Jejunostomy Tube Placement Research Articles

Development of a gastrocutaneous fistula from a marginal ulcer after repair of duodenal injury with pyloric exclusion

Duodenal trauma is rare but can be associated with significant morbidity and mortality (Pandey et al., 2011) [1]. Adjunct procedures, such as pyloric exclusion, can be performed to assist in surgical repair of these injuries. However, pyloric exclusion can lead to severe long-term complications associated with significant morbidity that can be difficult to repair. A 35-year-old man with a history of duodenal trauma from a gunshot wound (GSW) status post pyloric exclusion and Roux-en-Y gastrojejunostomy presented to the Emergency Department (ED) with complaints of abdominal pain and leakage of food particles and fluid from an open wound around his surgical scar. Computed tomography (CT) scan on admission showed a tract extending from the gastrojejunostomy anastomosis to the skin representing a fistula. Esophago-gastro-duodenoscopy (EGD) reconfirmed a large marginal ulcer that had fistulized to the skin. After nutritional repletion, the patient was taken to the operating room (OR) for takedown of the enterocutaneous fistula and Roux-en-Y gastrojejunostomy, closure of gastrostomy and enterotomy, pyloroplasty and feeding jejunostomy tube placement. The patient was re-admitted after discharge with abdominal pain, vomiting and early satiety. EGD showed gastric outlet obstruction and severe pyloric stenosis which was managed with endoscopic balloon dilation. This case represents the severe and potentially life-threatening complications that may occur after pyloric exclusion with Roux-en-Y gastrojejunostomy. Gastrojejunostomies are prone to marginal ulceration which can perforate if not adequately treated. Free perforations cause peritonitis, but if the perforation is contained it can erode through the abdominal wall creating the rare complication of a gastrocutaneous fistula. Even after restoration of normal anatomy with a pyloroplasty, patients may suffer additional complications such as pyloric stenosis requiring continued intervention.

The role of feeding jejunostomy on supportive enteral nutrition for resectable esofago-gastric junction adeno carcinoma undergoing total gastrectomy and esofago jejunostomy reconstruction: a case series

As a part of enhanced recovery after surgery protocols (ERAS), early gut feeding has been applicated in most of gastrointestinal surgery including major resection of distal esophageal and esofago-gastric junction adeno carcinoma. Early gut feeding could be applicated not only in minimally invasive procedure, but also in conventional open technique. Many enteral feeding option can be chosen as a post-operative enteral nutrition for the patients. One of them is feeding jejunostomy tube placement, we will evaluate the safety and effectivity of this enteral route on resectable esofago-gastric cancer resection. We will evaluate the clinical outcome of resectable esofago-gastric cancer patients and reconstruction, feeding jejunostomy tube has been placed as post-operative enteral route for nutrition. The patient with history of neoadjuvant therapy will be excluded. The post-operative evaluation including morbidity associated with jejunostomy tube will be recorded. We reported 4 cases, all of them had stage III esofago-gastric adeno carcinoma and conventional laparotomy technique was done. Feeding jejunostomy was tolerated well by the patients, enteral feeding can be started during the first 24 hours after surgery. No post-operative ileus and surgical site infection has been reported. Tube site infection was not found during this study. Although it still remains controversial, feeding jejunostomy tube was safe, feasible and has been tolerated well on esofago-gastric cancer patients undergoing resection and reconstruction.

Comparisons of nutritional status and complications between patients with and without postoperative feeding jejunostomy tube in gastric cancer: a retrospective study.

Feeding jejunostomy tube (FJT) enables early postoperative nutritional supply for gastric cancer patients undergoing surgery. However, the nutritional benefit of FJT may be accompanied by potential risk of increased complications, so both the nutritional improvement and the complication rates associated with FJT should be assessed. From January 2009 to December 2014, 715 consecutive patients underwent gastric cancer resection at the Peking Union Medical College Hospital in China. The perioperative nutritional index and incidence of complications in patients with FJT placement were retrospectively compared to those in patients without FJT placement. Nutritional data including albumin, prealbumin, hemoglobin, and high sensitivity C-reactive protein, the neutrophil-to-lymphocyte ratio (NLR), and Onodera's prognostic nutrition index (OPNI) were recorded at the following 3 timepoints: preoperatively, 1-week postoperatively, and 1-month postoperatively. Postoperative complications including surgical site infection, intra-abdominal infections, anastomotic leaks and gastroparesis were assessed. Multivariate logistic regression was used to study the association between FJT and complications. A total of 715 patients were included in the study. The mean age was 60.4 years and 72.2% were male. The overall characteristics between FJT and no-FJT groups were comparable. Of the 247 total gastrectomy cases, 98 (39.7%) had a FJT placed. Compared to the total gastrectomy patients without a FJT, the 98 patients with a FJT had a lower hemoglobin level (P=0.048) and NLR (P=0.030) preoperatively, and higher albumin (P=0.005), prealbumin (P<0.001), and hemoglobin (P=0.014) levels, a higher OPNI (P=0.027), and a lower NLR (P=0.005) 1-month postoperatively. Of the 468 subtotal gastrectomy cases, 87 (18.6%) had a FJT placed. Compared to the subtotal gastrectomy patients without a FJT, these 87 patients had a lower NLR (P=0.006) 1-week postoperatively, and a higher albumin level (P=0.009) 1-month postoperatively. In the multivariate analysis, FJT placement was not associated with postoperative adverse outcomes, including surgical site infection [odds ratio (OR) =1.21, P=0.79], intra-abdominal infection (OR =0.38, P=0.11), anastomotic leak (OR =0.58, P=0.53), reoperation (OR =0.22, P=0.23), gastroparesis (OR =6.35, P=0.08), or hospitalization for more than 30 days (OR =0.58, P=0.32). Early enteral nutritional support by FJT after gastrectomy tended to improve the nutritional status of patients, while it did not appear to increase the incidence rate of postoperative complications.

Barriers and Facilitators in Implementation of a New Postoperative Esophagectomy Care Pathway: A Qualitative Analysis

INTRODUCTION: We recently implemented a new esophagectomy pathway that included significant practice changes, including gastric ischemic preconditioning 4 weeks before definitive surgery and routine placement of feeding jejunostomy tubes. Practice pattern changes can prove challenging. We therefore sought to determine barriers and facilitators to the implementation at the provider level. METHODS: We utilized qualitative method guided by the Theoretical Domains Framework to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen interviews with providers involved with the pathway were conducted and analyzed using Matrix Analysis. RESULTS: Salient Theoretical Domains Framework domains identified included: knowledge, beliefs about consequences, and environmental context and resources. Facilitators included electronic health record tools (note templates including pathway components, pathway specific order set), patient satisfaction, and preliminary data suggesting reduced anastomotic leak rate. Barriers reported included hesitance to abandon previous practices and a desire for more concrete data prior to changing practice; these were most prevalent at the faculty level. Suggestions included improving post-discharge communication between providers and access to pathway documents by the clinical team. CONCLUSION: The Theoretical Domains Framework was successfully able to identify individuals’ perceived barriers and facilitators to implementation and adoption of an esophagectomy pathway that included significant practice changes. This analysis helped inform faculty about implementation and promoted communication between providers about pathway components. The findings of this qualitative methodology may inform future surgical patient care protocol implementations.

Clinical Benefits of Routine Feeding Jejunostomy Tube Placement in Patients Undergoing Esophagectomy

BackgroundRoutine placement of a feeding jejunostomy tube (FJT) following esophagectomy remains controversial due to the risk of complications including small bowel obstruction (SBO). This study aimed to evaluate FJT placement following esophagectomy. MethodsThis retrospective cohort study included consecutive 229 patients undergoing thoracoscopic esophagectomy between January 2010 and June 2020. Short-term outcomes, postoperative nutritional status, incidence of SBO, and long-term outcomes were compared between patients according to FJT placement. ResultsThe total operative duration was significantly longer in the FJT group compared to the no FJT group (P < 0.0001); however, no differences in overall or severe postoperative morbidity were observed. Body weight loss at discharge was significantly attenuated in patients with FJT (5% vs 7%, P = 0.001). Serum cholinesterase levels were significantly higher in patients with FJT (P = 0.002), while no difference was observed in serum albumin levels. At 6-month follow-up, no statistically significant differences were observed in serological markers or percentage body weight. The incidence of SBO was significantly higher in the FJT group (P = 0.006). The 5-year incidence of SBO was 12%. Patients in the FJT group had higher progression-free and overall survival compared to patients in the no FJT group (P = 0.041 and P = 0.033, respectively). A similar trend toward better survival in the FJT group was observed after propensity score matching. ConclusionsRoutine placement of FJT significantly improves postoperative nutritional status and may contribute to improved long-term survival but is associated with increased long-term risk of SBO.

Impact of Clinical Markers of Nutritional Status and Feeding Jejunostomy Use on Outcomes in Esophageal Cancer Patients Undergoing Neoadjuvant Chemoradiotherapy.

Background: Patients with esophageal cancer (EC) have high rates of malnutrition due to tumor location and treatment-related toxicity. Various strategies are used to improve nutritional status in patients with EC including oral and enteral support. Methods: We conducted a retrospective analysis to determine the impact of malnutrition and prophylactic feeding jejunostomy tube (FJT) placement on toxicity and outcomes in patients with localized EC who were treated with neoadjuvant chemoradiation therapy (nCRT) followed by esophagectomy. Results: We identified 125 patients who were treated with nCRT between 2002 and 2014. Weight loss and hypoalbuminemia occurred frequently during nCRT and were associated with multiple adverse toxicity outcomes including hematologic toxicity, nonhematologic toxicity, grade ≥3 toxicity, and hospitalizations. After adjusting for relevant covariates including the specific nCRT chemotherapy regimen received and the onset of toxicity, there were no significant associations between hypoalbuminemia, weight loss, or FJT placement and relapse-free survival (RFS) or overall survival (OS). FJT placement was associated with less weight loss during nCRT (p = 0.003) but was not associated with reduced toxicity or improved survival. Conclusions: Weight and albumin loss during nCRT for EC are important factors relating to treatment toxicity but not RFS or OS. While pretreatment FJT placement may reduce weight loss, it may not impact treatment tolerance or survival.

S2774 An Unusual Case of Duodenal Obstruction from an Unsuspected Intramural Hematoma

INTRODUCTION: Intramural duodenal hematoma (IDH) is an unusual presentation after blunt abdominal trauma. IDH rarely leads to gastric outlet obstruction (GOO), acute pancreatitis, obstructive cholestasis, and gastrointestinal hemorrhage. We report first case of delayed presentation of large IDH associated with acute pancreatitis and GOO four months after abdominal trauma. CASE DESCRIPTION/METHODS: A 53-year-old man with history of diabetes mellitus, alcohol use disorder presented with upper abdominal pain, nausea and vomiting of 2 days duration. Reports fall on to the edge of bathtub and hitting his abdomen 4 months ago. Abdominal exam revealed a non-tender palpable mass in the epigastrium. Labs were significant for elevated AST-214, ALT-63, ALP- 218, lipase-419, and CA 19-9 -377.8. A CT scan of Abdomen showed a large duodenal intramural mass without enhancement and upstream GOO, which is new compared to prior CT scan done a year ago for other reasons. An MRI of the abdomen showed a large heterogeneous duodenal filling defect, with no internal enhancement likely representing a hematoma (Figure 1). Patient underwent EGD and Endoscopic ultrasound(EUS) that showed a submucosal duodenal mass occupying the entire lumen of the duodenum (Figure 2). FNA showed many inflammatory and necrotic cells and was non-diagnostic. Patient had persistent obstruction despite one week of conservative therapy with Nasogastric decompression and TPN (Figure 3). He underwent surgical hematoma evacuation with a feeding jejunostomy tube placement and was discharged on post-operative day 7 after tolerating oral feeds, normalization of lipase and LFTs. DISCUSSION: Most cases of IDH are secondary to blunt abdominal trauma. Spontaneous IDH occurs in patients with bleeding disorders, anticoagulation therapy, vascular collagen diseases, or after invasive endoscopic procedures. IDH is more frequent among children. Due to its anatomic location and high submucosal vascularity distal duodenum is the most common site involved. Symptomatic patients present with GOO symptoms. Compression of the ampulla or pancreatobiliary ducts can cause acute pancreatitis and obstructive jaundice. Cross sectional imaging aids in diagnosis and to evaluate for complications such as perforation or retroperitoneal hemorrhage. EGD and EUS are helpful when imaging is inconclusive. Most patients improve with conservative management by 1 week. Surgical, image guided or endoscopic drainage is needed in patients who fail conservative management or develop complications.Figure 1.: A: CT scan of abdomen showing large heterogeneous filling defect ( arrow) extending from 1st to 3rd portion of duodenum, measuring at least 13 cm × 5.6 cm resulting in upstream gastric outlet obstruction, as evidenced by distended stomach and contrast not passing in to small bowel. B: MRI of abdomen- Post contrast subtraction films showing large heterogenous filling defect (arrow) with no internal enhancement, likely representing a hematoma.Figure 2.: A: ESD showing large 4-5 cm smooth, subepithelial duodenal mass involving the bulb and the duodenal sweep occupying 99% of the lumen of the duodenum. B: -Linear EUS imaging showing a 37.2 mm × 60.5 mm subepithelial lesion in the duodenal bulb. Due to local inflammation and the large size of the lesion, the layers of the duodenum could not be well defined.Figure 3.: Upper Gastrointestinal series showing filling defect in the lateral aspect of the duodenum with a narrow trail of contrast coursing in the residual medial lumen at 1 week of conservative therapy.

Complications of Jejunostomy Feeding Tubes: A Single Center Experience of 546 Cases

IntroductionAdequate perioperative nutrition is critical for the success of surgical outcomes. Jejunostomy feeding tube placement may ensure enteral feeding access; however, these types of tubes have had variable reported rates of dysfunction/morbidity. The aim of our study was to report our experience with jejunostomy feeding tube placement and the long-term outcomes following complex foregut surgery. MethodsWe performed a review of all of our jejunostomy feeding tube placement patients from 1/1/2010 until 7/1/2018. The indication for surgery and primary operation were recorded. All adverse events related to the jejunostomy were recorded during the entire duration of tube access. Social “hassle-factor” issues were also reported, including the number of “jejunostomy-related” phone calls, reinsertion and related placement studies, and readmissions pertaining to jejunostomy-associated complications. ResultsDuring the study period, 542 primary procedures were performed with secondary jejunostomy placement. Jejunostomy-related adverse events occurred in 22.0% of patients (n = 119/542); 12.0% (n = 65/542) were dislodged tubes, 6.0% (n = 30/542) clogged tubes; 5% (n = 25/542) leaking tubes, and 2.8% (n = 15/542) site infections. Tube dysfunctions initiated 244 reinsertion/placement studies in 107 patients, 20 jejunostomy tube-related readmissions, and 78 phone calls to providers for tube dysfunction. Adverse event rates differed significantly between groups (p < 0.001), with esophagogastric resection adverse event rates of 42.3% versus 19.2% for pancreatic ablations. DiscussionJejunostomy feeding tubes resulted in adverse events in less than a third of patients. Patient-related hassle must be communicated preoperatively in order to prevent jejunostomy tube-related morbidity. Optimal early and late jejunostomy feeding optimization varies based on preoperative patient comorbidities, type of operation, and the need for adjuvant oncology therapy.

Refractory Hyperemesis Gravidarum in a Patient with Type 1 Diabetes Treated with Laparoscopically Assisted Feeding Jejunostomy Tube Placement

Refractory Hyperemesis Gravidarum in a Patient with Type 1 Diabetes Treated with Laparoscopically Assisted Feeding Jejunostomy Tube Placement

Jejunostomy-technique and controversies.

Malnutrition is quite common in patients with esophageal cancer, and can be secondary to tumor related dysphagia or treatment side effects. Traditionally, open feeding jejunostomy tube was performed in all patients undergoing surgical treatment of esophageal cancer. With the advent of minimally invasive approaches, placement of the jejunostomy tube can be currently accomplished with either robotic or laparoscopic assistance. Here, we discuss the technical aspects as well as the pros and cons of a minimally invasive jejunostomy feeding tube placement.

Gastric cancer in a post pancreaticoduodenectomy patient with ATM mutation – interesting case

Background: 50 y old female with past history of ampullary cancer diagnosed 10 years prior. Patient underwent a pancreaticoduodenectomy and pathology was consistent with a poorly differentiated T4 lesion which was node negative and margin negative with lymphovascular and perineural invasion. Patient underwent adjuvant chemotherapy followed by chemo-radiation. She was found to have ATM mutation on genetic panel analysis. She was lost to follow up after completing surveillance for 5 years. She presented with anemia several years later and underwent an endoscopy which revealed an ulcerated mass in the stomach just proximal to the gastrojejunal anastomosis. Methods: She underwent endoscopic ultrasound which revealed a T2 lesion and no significant regional lymphadenopathy. Patient underwent staging scans including a PET-CT which did not demonstrate metastatic disease. She underwent oncologic surveillance with mammography and pap smear and gynecologic examination. She was started on perioperative regimen of FLOT (5-FU/leucovorin/oxaliplatin/docetaxel) and was taken to the operating room after restaging scans. Results: She underwent an exploratory laparotomy, extensive lysis of adhesions, subtotal gastrectomy and roux-en-y reconstruction of the biliopancreatic limb and the alimentary limb as well as completion celiac, hepatic and splenic lymphadenectomy with feeding jejunostomy tube placement. Patient was discharged home with an uneventful postoperative recovery. Conclusion: Final pathology demonstrated poorly differentiated diffuse type gastric adenocarcinoma with submucosal invasion( T1N0) with negative margins . Patient to complete perioperative chemotherapy with FLOT and then proceed with surveillance.

Opening the Black Box: How Interventional Radiology Can Help Our Patients in Hospice and Palliative Care (SA504)

•Describe indications for four commonly used interventional procedures for patients with serious illness.•Explain the clinical experience of patients undergoing a tunneled catheter placement, kyphoplasty, celiac plexus block, and other common procedures.•Identify the most and least cost-effective procedures that VIR clinicians can perform for four common palliative care conditions. Thanks to rapidly advancing technology, the number of clinical interventions to treat serious illnesses grows each year. Vascular Interventional Radiology (VIR) is at the center of medicine’s procedural growth and has become a vital part of clinicians’ symptom management toolbox. Unfortunately, most clinicians practicing Palliative Care (PC) have had little interaction with VIR providers and, while often understanding the purpose of available procedures, have not seen and cannot explain to patients the experience of undergoing common VIR procedures. How can PC and hospice clinicians understand the complex and ever changing landscape of VIR? In this explanation and demonstration-heavy concurrent session, an academic palliative care and hospice physician with training in business and the Interventional Radiology residency/fellowship program director at a large academic hospital will join together to expose attendees to the ‘how and why’ of VIR. Evidence-based indications for common procedures like gastrostomy and jejunostomy feeding tube placement, thoracic and abdominal drainage catheter placement, kyphoplasty, celiac plexus block, and others will be provided and these procedures will be explained using a combination of hands-on demonstration, video, and illustration. In addition to the clinical aspects of each procedure, the patient experience of undergoing these interventions will be described and samples of the tools and devices being discussed will be circulated through the audience to encourage high-level understanding. Under the Medicare Hospice benefit, hospices must bear the cost of these interventions. We will discuss the relative costs of typical interventions for ascites, pleural effusion, and compression fractures and share strategies to ensure interventions are cost-effective both initially and over time. Remaining current with technological advances is difficult, especially for clinicians who practice outside the acute hospital setting. This concurrent session will shine light in the black box of VIR to improve care for many of our patients.

Jejunostomy tube-induced intussusception

Intussusception involves the telescoping of a segment of bowel into an adjacent segment. It is the leading cause of intestinal obstruction in the pediatric age group; however, it is relatively rare and accounts for just about 1% of the cases of small bowel obstruction in adults. Jejunostomy tube-induced intussusception is an extraordinarily rare complication of feeding jejunostomy tube placement, the exact mechanism of which is not definitively known. The diagnosis of jejunostomy tube-induced intussusception is not easy as it generally does not interfere with the enteral feeding. Computed tomography (CT) scan is widely considered to be the imaging modality of choice in the diagnostic evaluation of adult intussusception. The finding of a heterogeneous sausage-shaped soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum is virtually pathognomonic of intussusception. Surgery is the mainstay of management in an adult with intussusception. Nonoperative treatment strategies including radiologic reductions aided by hydrostatic/contrast/air enemas, which have mainly been attempted in the pediatric age group, have shown unpredictable results and are not recommended in adults. We present an unusual cause of jejunostomy tube-induced intussusception following a salvage laryngopharyngoesophagectomy and gastric pull-up in a patient with a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region. A high degree of suspicion among clinicians and timely imaging with a CT scan are prerequisites for diagnosing intussusception in patients who complain of persistent gastrointestinal symptoms, especially with a jejunostomy tube in situ.

Critical analysis of feeding jejunostomy following resection of upper gastrointestinal malignancies.

AIMTo assess nutritional recovery, particularly regarding feeding jejunostomy tube (FJT) utilization, following upper gastrointestinal resection for malignancy.METHODSA retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, from January 2001 to June 2014. Patient demographics, the approach to esophagectomy, the extent of gastrectomy, FJT placement and utilization at discharge, administration of parenteral nutrition (PN), and complications were evaluated. All patients were followed for at least ninety days or until death.RESULTSThe 287 patients underwent upper GI resection, comprised of 182 esophagectomy (n = 107 transhiatal, 58.7%; n = 56 Ivor-Lewis, 30.7%) and 105 gastrectomy [n = 63 subtotal (SG), 60.0%; n = 42 total (TG), 40.0%]. 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs 44.8%, P < 0.0001), of whom most had undergone TG (n = 39, 92.9% vs n = 8 SG, 12.9%, P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 d vs 17.1 d, P = 0.076). Upon discharge, 87 esophagectomy patients (48.1%) were taking enteral feeds, with 53 (29.3%) fully and 34 (18.8%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n = 3, 7.7%) or partially (n = 17, 43.6%) dependent on tube feeds, compared with 5 of 8 SG patients (10.6%), all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs 29.3%, P = 0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n = 11, 23.4% vs n = 7, 3.9%, P = 0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group (n = 6), all after TG, compared to 1 esophagectomy patient (12.8% vs 0.6%, P = 0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.CONCLUSIONNutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.

Complications after Feeding Jejunostomy Tube Placement for Gastroesophageal Cancer

RESULTS: We reviewed 1,847 CTs among 491 patients who met inclusion criteria (59% men), with inter-rater reliability 0.85 for the panel. Mean age was 60 12 years; mean follow-up time 13 8 months. Ventral incisional hernia occurred in 41% and differed across diagnoses: urologic/gynecologic (30%), colorectal (53%), and all others (56%) (p<0.001). In CPH analysis, incision location, cancer type (Table), open operation (HR 2.07 [95% CI, 1.18-3.63]), surgical site infection (HR 1.58 [95% CI, 1.06-2.34]), and body mass index (HR 1.06 [95% CI, 1.03-1.08]) were associated with VIH, adjusting for stage, age, chemotherapy, smoking, and steroid use.

An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma: A seven-institution analysis of 837 patients from the U.S. gastric cancer collaborative.

Jejunostomy feeding tubes (J-tubes) are often placed during resection for gastric adenocarcinoma (GAC). Their effect on postoperative complications and receipt of adjuvant therapy is unclear. Patients who underwent curative-intent resection of GAC at seven institutions of the U.S. Gastric Cancer Collaborative from 2000 to 2012 were identified. The associations of J-tubes with postoperative complications and receipt of adjuvant therapy were determined. Of 837 patients, 265 (32%) received a J-tube. Patients receiving J-tubes demonstrated greater incidence of preoperative weight loss, lower BMI, greater extent of resection, and more advanced TNM stage. J-tube placement was associated with increased infectious complications (36% vs. 19%; P < 0.001), including surgical-site (14% vs. 6%; P < 0.001) and deep intra-abdominal (11% vs. 4%; P < 0.001) infections. On multivariate analysis, J-tubes remained independently associated with increased risk of infectious complications (all: HR = 1.93; P = 0.001; surgical-site: HR = 2.85; P = 0.001; deep intra-abdominal: HR = 2.13; P = 0.04). J-tubes were not associated with increased receipt of adjuvant therapy (HR = 0.82; P = 0.34). Subset analyses of patients undergoing total and subtotal gastrectomy similarly demonstrated an association of J-tubes with increased risk of infectious outcomes and no association with increased receipt of adjuvant therapy. J-tube placement after resection of gastric adenocarcinoma is associated with increased postoperative infectious outcomes and is not associated with increased receipt of adjuvant therapy. Selective use of J-tubes is recommended.

Feeding jejunostomy tube placement during resection of gastric cancers

BackgroundFeeding tube placement is common among patients undergoing gastrectomy, and national guidelines currently recommend consideration of a feeding jejunostomy tube (FJT) for all patients undergoing resection for gastric cancer. However, data are limited regarding the safety of FJT placement at the time of gastrectomy for gastric cancer. MethodsThe 2005–2011 American College of Surgeons National Surgical Quality Improvement Program Participant User Files were queried to identify patients who underwent gastrectomy for gastric cancer. Subjects were classified by the concomitant placement of an FJT. Groups were then propensity matched using a 1:1 nearest neighbor algorithm, and outcomes were compared between groups. The primary outcomes of interest were overall 30-d overall complications and mortality. Secondary end points included major complications, surgical site infection, and early reoperation. ResultsIn total, 2980 subjects underwent gastrectomy for gastric cancer, among whom 715 (24%) also had an FJT placed. Patients who had an FJT placed were more likely to be male (61.6% versus 56.6%, P = 0.02), have recent weight loss (21.0% versus 14.8%, P < 0.01), and have undergone recent chemotherapy (7.9% versus 4.2%, P < 0.01) and radiation therapy (4.2% versus 1.3%, P < 0.01). They were also more likely to have undergone total (compared with partial) gastrectomy (66.6% versus 28.6%, P < 0.01) and have concomitant resection of an adjacent organ (40.4 versus 24.1%, P < 0.01). After adjustment with propensity matching, however, all baseline characteristics and treatment variables were highly similar. Between groups, there were no statistically significant differences in 30-d overall complications (38.8% versus 36.1%, P = 0.32) or mortality (5.8 versus 3.7%, P = 0.08). There were also no differences in major complications, surgical site infection, or early reoperation. Operative time was slightly longer among patients with feeding tubes placed (median, 248 versus 233 min, P = 0.01), but otherwise there were no significant differences in any outcomes between groups. ConclusionsConcomitant placement of FJT at the time of gastrectomy may result in slightly increased operative times but does not appear to lead to increased perioperative morbidity or mortality. Further investigation is needed to identify the patients most likely to benefit from FJT placement.

Sleeve Gastrectomy Leaks: The Way we Treat it

endoscopic clips and endoscopic suturing are new techniques not part of the algorithm that are becoming more widely used with positive results [10-13]. When other conservative methods have failed, RYGB or Roux-en-Y fistula jejunostomy have also been proposed as alternative treatments for non-healing gastric leaks [9,14-17]. With the increasing experience of surgeons performing LVSG and treating complications, Nedelcu has recently proposed an algorithm for treatment based on size of the leak and stenosis of the sleeve [18]. The aim of this study was to review our experience and outcomes of LVSG treatment and design an algorithm of successful treatment. Approval for this study was granted by the Banner Health institutional review board. Patients were identified from the authors’ prospectively maintained bariatric database. All patients between 2012 and 2014 were reviewed, and 11 patients were identified and treated at our institution. Data collected included patient demographics, operative, endoscopic and medical interventions, and follow-up outcomes. Patient demographics included age, sex, body mass index (BMI), co-morbidities, number of days from initial surgery until recognition of leak. Operative data included location of initial surgical intervention, need for repeat interventions and type, placement of feeding jejunostomy tube. Endoscopic interventions included use of OVESCO ® over the scope clip, Boston Scientific fully covered WallFlex™ esophageal stent, Apollo Over Stitch™. Post-operative data included need for multiple interventions, nutritional support, and number of days until resolution of leak. During the study period from 2012-2014, 556 patients underwent LVSG for the treatment of morbid obesity. We identified a total of 8 LVSG leaks (1.4%). Three patients did not have initial surgery at our institution and were transferred from an outside hospital for further treatment.

An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma: A seven-institution analysis of 837 patients from the U.S. Gastric Cancer Collaborative.

120 Background: A recent single institutional study demonstrated that jejunostomy feeding tubes (J-tubes) placed during resection of gastric adenocarcinoma (GAC) are associated with increased complications and no change in receipt of adjuvant therapy. Our aim was to validate these findings in a large multi-institutional cohort. Methods: All patients who underwent resection for GAC at 7 institutions participating in the U.S. Gastric Cancer Collaborative from 2000-2012 were identified. Patients with metastatic disease were excluded. Univariate and multivariate logistic regression were performed to assess the association of J-tubes with postoperative complications and receipt of adjuvant therapy. Subset analysis of patients who underwent total vs subtotal gastrectomy was also performed. Results: Of 965 patients, 837 were included for analysis, of whom 265 (32%) received a J-tube. Patients receiving J-tubes demonstrated greater incidence of preoperative weight loss, lower BMI, greater extent of resection, and more advanced TNM stage. J-tube placement was associated with increased infectious complications (36% vs 19%;p&lt;0.001), including surgical site infections (14% vs 6%;p&lt;0.001) and deep intra-abdominal infections (11% vs 4%;p&lt;0.001). On multivariate analysis, J-tubes remained independently associated with increased risk of infectious complications (HR=1.93;p=0.001), surgical site infections (HR=2.85;p=0.001), and deep intra-abdominal infections (HR=2.13;p=0.04). J-tubes were not associated with increased receipt of adjuvant therapy (HR=0.82;p=0.34). Subset analysis of patients undergoing total and subtotal gastrectomy similarly demonstrated an association of J-tubes with increased risk of infectious outcomes andno association with increased receipt of adjuvant therapy. Conclusions: J-tubes placed during resection of gastric adenocarcinoma are independently associated with increased postoperative infections and are not associated with increased receipt of adjuvant therapy, despite being placed in patients with advanced TNM stage tumors. Selective use of J-tubes is recommended.

Unusual complication of multiple splenic abscesses arising from a feeding jejunostomy tube subsequent to total gastrectomy: A case report and literature review

Splenic abscess is a rare clinical entity. The present study reports a case of a patient that suffered from splenic abscess secondary to septicemia resulting from Klebsiella pneumoniae infection following the removal of the feeding jejunostomy tube that was utilized subsequent to the patient undergoing total gastrectomy as part of the treatment regimen for gastric adenocarcinoma. The early clinical presentation was nonspecific and multiple splenic abscesses were subsequently identified. To reduce the risks of an additional surgical procedure in this particular patient, laparoscopic assisted splenotomy and catheter drainage were performed. Due to the severe complications that occurred in the present patient, no adjuvant chemotherapy was administered. Therefore, the unusual complication of splenic abscess subsequent to total gastrectomy should be noted, and the routine feeding jejunostomy tube placement at the time of total gastrectomy should be discussed and re-assessed.