Jejunostomy Placement Research Articles

AHP P04 Utilisation of Jejunostomy (JEJ) placement post Oesophagogastrectomy (OG) surgery and the difference in unintentional weight loss between patients who were placed with a JEJ at the time of surgery compared to those without

Abstract Background The optimal pathway for reinstating nutrition orally or enterally remains a matter of debate post OG surgery. Historically all patients undergoing OG had routine JEJ placement and there are many studies to support this. However more recently, some trusts are moving away from this notion and opting for selective JEJ placement due to suboptimal tube utilisation rates, psychological impact for patients, enhanced recovery after surgery (ERAS) pathways, wider range of oral nutritional supplements on the market, adaptive hospital menus and snack boxes, Naso-jejunal tubes (NJT) being placed instead of JEJ, JEJ tube complications and more enhanced specialist Dietetic input. Methods Data was collected retrospectively from electronic notes for all patients who underwent an OG between April 2020- April 2021 which was during the start of the covid pandemic. The data was reviewed for 2 years following their surgery and compared percentage weight loss of patients with JEJ placed versus patients without at 1-2 months, 3 months, 6 months, 9 months, 1 year and 2 years post surgery. Utilisation rates of JEJ tube were also reviewed alongside establishing if patients did not have JEJ placement at time of OG, required enteral feeding as part of their recovery. Results 58 OG’s Conducted between 30/4/2020-29/4/21, of which 65.5% had JEJ placed. Conclusions Selective JEJ placement during OG surgery requires careful consideration given 23.7% patients didn't use JEJ post discharge and 2years post OG, weight loss was the same in both groups. However, 1year post OG, the non-JEJ group lost nearly double the amount to the JEJ group, highlighting further research is required to inform this debate; especially as the weight loss could be attributed to cancer recurrence which has not been accounted for. Collaborative working between Dietitians, surgeons and nurse specialists is essential if selective JEJ placement is to occur. Data will be repeated during non-covid times to yield more meaningful data.

Safety and efficacy of direct percutaneous endoscopic jejunostomy placement in patients with previous upper gastrointestinal resection: A retrospective cohort study.

Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery. We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull-up. Adverse events (AEs) were graded perAmerican Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention. Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history. DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.

Reconstruction of the upper gastrointestinal tract using intra-thoracic Roux-en-Y technique after caustic agent ingestion: a case report from Aleppo, Syria

BackgroundCaustic substance ingestion is a high-risk medical emergency associated with high mortality and morbidity. To date, there are several treatment options with no standard method of care.Case presentationWe report a case of a corrosive agent ingestion complicated with third-degree burns and severe stenosis of the esophagus and gastric outlet. After failure of conservative treatment, the patient underwent jejunostomy placement for nutritional support followed by transhiatal esophagectomy with gastric pull-up and intra-thoracic Roux-en-Y gastroenterostomy with good outcomes. The patient recovered from the procedure and has been tolerating oral intake very well with significant weight gain.ConclusionWe put a new technique for treating severe gastrointestinal injuries caused by corrosive agent ingestion that resulted in both esophageal and gastric outlet strictures. These rare complex cases requires difficult treatment decisions. We believe that this technique provides many benefits for such cases and might be a feasible alternative for colon interposition.

Balloon-assisted Jejunostomy Placement

Jejunal feeding is indicated in patients with functional or physical abnormalities that prevent gastrostomy tube placement or feeding. J-tubes are most often placed using one of four techniques: Open surgical, laparoscopic, needle catheter, or direct percutaneous placement, depending on the patient needs and expertise of the surgeon. Minimally invasive techniques are considered standard of care, and thus, J-tube placement most often occurs through laparoscopic methods. While percutaneous insertion using balloon dilation rather than serial dilation has shown greater success rates, lower complication rates, and alleviates patient discomfort in G-tube placement, this procedure has not been utilized for J-tube placement. Here, we report a balloon-assisted jejunostomy placement technique utilized to replace a previous surgical jejunostomy tube that the cutaneous tract had healed over.

OGC P18 Feeding jejunostomy complications after oesophagectomy: a quality improvement project at a tertiary referral centre

Abstract Background A feeding jejunostomy is one method to provide adequate nutrition after oesophagectomy. This bypasses the anastomosis allowing healing before oral feeding resumes. However, routinely using feeding jejunostomies may not be appropriate for patients within an Enhanced Recovery After Surgery protocol due to complications. Feeding jejunostomies have 3–61% morbidity, with mechanical (i.e tube dislodgement) and non-mechanical (i.e. site infection) complications plus associated increased length of stay. The local standard after oesophagectomy is routine feeding jejunostomy placement. However, selective, rather than routine feeding jejunostomy placement may therefore be warranted. Aim Conduct a quality improvement project addressing the local feeding jejunostomy complication rate after oesophagectomy. Methods Cycle 1: A review of oesophagectomies between 2018–2021 assessing complications using the Clavien-Dindo classification. An existing database of oesophagectomies was screened for patients undergoing concurrent feeding jejunostomy insertion. Patients ≥18 were included, whilst any indication for oesophagectomy was included. Patients lacking information on type and bore of jejunostomy tube inserted were excluded. Demographics, jejunstomy tube type and bore, complication and Clavien-Dindo grade of complication were recorded. The Charlson comorbidity score of each patient was determined to help find a population at risk. Intervention: Findings to be presented at a departmental audit meeting, with patient risk stratification to identify a cohort at risk. Cycle 2: re-audit (July 2022 - July 2023) as per cycle 1 after presentation. Improvement = fewer jejunostomy-specific complications. Results 110 patients were included, with a median age of 65.5 (IQR 61.0–72.0). 81.8% patients (n=90) sustained a complication, mostly Clavien-Dindo grade II. Jejunostomy-specific complications occurred in 21.8% patients (n=24), with the commonest jejunostomy-specific complication being a leak (44.8%). 4 ‘major’ (Clavien-Dindo ≥III) jejunostomy-specific complications were reported. No ischaemic small bowel necrosis was reported, significantly less than a prior audit (0.0% vs. 3.74%, p=0.029). Demographics/ Charlson comorbidity score, jejunostomy type inserted (JJ tube, 15F or 9F) and jejunostomy insertion method (open/ laparoscopic) did not impact overall or major feeding jejunostomy-specific complication rate. Conclusions This first cycle agrees with the reported complication rate in the literature. Though a population at risk could not be determined, reviewing local non-specialist centres may aid this, to reduce future complications. The literature would support a more selective approach to feeding jejunostomy insertion and as such this should be taken to reduce post-insertion complications. Continued prominent advice regarding inotropes may prevent ischaemic bowel. We aim to introduce clear warnings to the local ERAS protocol over the concurrent use of jejunostomy feed and inotropes, whilst electronic warnings flagging concurrent jejunostomy feed and inotrope prescribing are being worked upon. Moreover, poor hospital coding of jejunostomies may have limited the cohort, preventing determining a cohort at risk of feeding jejunostomy insertion.

211. STUDENT (CROWD SOURCED) ASSESSMENT OF LAPAROSCOPIC ASSISTED PERCUTANEOUS NEEDLE JEJUNOSTOMY PLACEMENT IS EQUIVALENT TO EXPERT ASSESSMENT, EXCEPT FOR PROCEDURE-SPECIFIC STEPS

Abstract Objective and Structured Assessment of Technical Skills (OSATS) is an important and frequently used method to give feedback on surgical skills during surgical training. Feedback is usually given by qualified surgeons, but their availability is often limited. Aim of our study was to investigate whether OSATS performed by novice medical students and students trained in a laparoscopic jejunostomy simulation setup was equivalent to OSATS performed by experts in laparoscopic assisted percutaneous needle jejunostomy placement. Fifty-six volunteers (32 inexperienced students, 12 trained students and 12 expert surgeons) were invited to participate. An instruction video with the procedure’s essential steps was displayed on an online survey platform. Thereafter five edited videos with essential steps of the procedure, performed by operators with a different level of expertise, were shown. Each video was followed by a standardized OSATS form, assessing nine different procedural aspects: fluency of the entire procedure, use of instruments, tissue respect, placement of stitches, tissue bridge between bowel and wall, submucosal needle tunneling, advancing the catheter, camera use and end result. Nonparametric statistics were used. Thirty-seven (66%) volunteers—21 novice students (66%), 8 trained students (67%) and 8 surgeons (67%)—completed all five forms within 30 days. Median time to complete OSATS forms for novice students, trained students and experts was 22, 21 and 14.5 days respectively (p = 0.88). Median time needed per video was 825, 881 and 793 seconds respectively (p = 0.60). Average total scores per item showed no differences between novice students, trained and experts, except for items submucosal needle tunneling” (p = 0.0082) and advancing the catheter” (p = 0.0154) which both were rated higher by experts than by both groups of students. Using standardized OSATS to evaluate laparoscopic assisted percutaneous needle jejunostomy placement, steps with common laparoscopic skills were rated equally by novice students, trained students and experts. These skills can be correctly evaluated without advanced training of the evaluator. Two procedure-specific items were rated differently by experts, compared to students. These procedure-specific items probably need more advanced training, explaining the different appreciation of the assessed manipulations by expert surgeons.

Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients. Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed. Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients ( P = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant. Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Technical notes and outcomes of robot-assisted and laparoscopic jejunostomy placement for tube feeding after esophagectomy

B. Feike Kingma, Matias M. Turchi, Romina Lovera, Mauricio Ramirez, Adolfo Badaloni, Richard van Hillegersberg, Jelle P. Ruurda, Alejandro Nieponice

P-OGC05 The introduction of an Upper Gastrointestinal (UGI) specific menu can reduce the need for routine jejunostomy (JEJ) placement following UGI Cancer resection

Abstract Background Despite the fact that early oral feeding (EOF) after the surgical resection of oesophageal and gastric tumours is safe, and is associated with favourable early in-hospital outcomes, sooner return to physiological GI function and hospital discharge, there can still be some reluctance in establishing EOF. Concerns remain around risk of anastomotic leak, pneumonia, Naso-gastric tube (NGT) reinsertion, re-operation, readmissions and mortality. However, when utilising EOF, a reduction in length of stay, earlier removal of NGT and earlier initiation of soft diet can be observed. JEJ placement is beneficial however complications can arise and the optimal nutritional pathway remains debatable. Methods Patient satisfaction surveys were conducted amongst UGI Cancer patients following Cancer resection and analysed pre and post UGI menu development and staff training. Expert UGI Patient volunteers assisted in the UGI menu development through food tastings producing a new menu in collaboration with the catering department. The new menu was launched and an UGI snack box provided to the UGI Enhanced Recovery Unit (ERAS). Oral intake of Diet and Oral Nutritional Support was analysed for calorie and protein content post menu change, ward staff training and specialist UGI dietetic counselling. This was then compared with calculated minimum estimated nutritional requirements. Results Of the ten patients audited pre discharge: Remaining 1 patient achieved 51% of protein requirements, below the aim of 60%. No patient audited required supplementary Enteral feeding via JEJ or Naso-jejunal tube Patient satisfaction surveys were completed prior to catering staff training and menu revision, after the new menu was implemented. The results show a significant improvement in patient satisfaction following UGI menu implementation. Conclusions Specialist UGI RD support, UGI specific menu and Oral Nutritional Support can reduce the need for routine JEJ placement in favour of on an individual patient basis. Collaborative working between UGI Dietitians, Ward staff, Catering staff and Expert patients is required for UGI specific menu development to be effectual. This audit is limited to small numbers due to adapted operational procedures during the pandemic. This audit will be repeated on a larger scale to yield more meaningful data. Future audit will capture data on how many UGI patients went on to require enteral nutritional support with three months of discharge.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

EP.WE.1015Management of Boerhaave Syndrome

Abstract Aim Boerhaave’s Syndrome is a rare and fatal condition, characterised by a distal oesophageal tear induced by an abrupt rise in intra-luminal pressure. Treatment remains controversial; we present a recent case and review relevant literature. Methods A retrospective analysis of case-notes was performed, and a literature review undertaken on PubMed. Results A 58-year-old male presented as an emergency with severe chest pain, having choked and vomited following the ingestion of steak. Computed tomograpy scan of the thorax demonstrated a large pneumomediastinum associated with an oesophageal perforation on the anterior wall and bilateral pleural effusions. A primary laparoscopic repair was performed with jejunostomy placement for feeding. The post-operative period was complicated by a prolonged stay on intensive care with sepsis secondary to mediastinitis. A contrast swallow performed eleven days post-surgery confirmed no persistent leak and the patient was discharged five days later. Boerhaave’s syndrome accounts for 10% of oesophageal perforations and is typically associated with a history of overindulgence and vomiting. Stable patients with a contained disruption and minimal contamination, can be managed conservatively. Endoscopic therapies include clipping small perforations, self-expanding stents for larger defects, and endoluminal vacuum therapy. Operative interventions comprise primary repair, debridement and drainage of thoracic cavity, diversion operations and single stage resection with or without primary reconstruction. Conclusion Boerhaave’s Syndrome is associated with significant morbidity and mortality, but with early recognition and prompt intervention, patients can be successfully managed. Options include conservative, endoscopic and surgical, depending upon the site and size of the perforation.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases

Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy. We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation. Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively. A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018

BackgroundThe purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018. Materials and methodsClaims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting. ResultsVolume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (−32.2%). While endoscopic placement decreased from 133,658 to 81,171 (−39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (−25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (−10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period. ConclusionDe novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance. Summary statementDecreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Comparison of laparoscopy versus mini-laparotomy for jejunostomy placement in patients with gastric adenocarcinoma.

Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement. A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission. A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group. The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement.

Platelet-to-lymphocyte ratio is correlated with a delay in feeding resumption following a transhiatal esophagectomy with cervical anastomosis

IntroductionThe lymphocytic population, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are prognostic tools predictive of adverse outcomes for several solid tumors and oncologic surgeries, one of which is esophageal adenocarcinoma. Furthermore, delayed resumption of oral feeding postoperatively is associated with significant morbidity. Given the controversies regarding post-op nutritional support in these patients, this study investigates the prognostic role of the lymphocytic percentage, the NLR, and the PLR in predicting prolonged length of hospital stay (LOHS) and ICU stay (LOICUS) as well as delayed oral feeding following transhiatal esophagectomy (THE) for adenocarcinoma of the esophagogastric junction (AEG).MethodsForty consecutive patients who underwent transhiatal esophagectomy performed by a single surgeon for Siewert type II and type III adenocarcinoma of the esophagogastric junction at a tertiary referral center were selected. Retrospective data collection was performed from the patients’ medical records, and statistical analysis was performed using Pearson correlation and Student’s t test and Chi-square testing.ResultsAn increased LOHS was correlated with a lower preoperative lymphocyte percentage (p = 0.043), higher NLR (p = 0.010) and PLR (p = 0.015), and an increased number of packed red blood cell (PRBC) transfusions perioperatively (p = 0.030). An increased LOICUS was correlated with a lower preoperative lymphocyte percentage (p = 0.033), higher NLR (p = 0.018) and PLR (p = 0.044), an increased number of PRBC transfusions (p = 0.001), and patients’ comorbidities (p < 0.05). A delay in feeding resumption was correlated with a lower preoperative lymphocyte percentage (p = 0.022), higher NLR (p = 0.004) and PLR (p = 0.001), an increased PRBC transfusions (p = 0.001), and diabetes mellitus (p = 0.033). Multivariate analysis with automatic linear modeling showed that only the preoperative PLR was a powerful predictor for the delay of feeding resumption (p < 0.01).ConclusionThe lymphocyte percentage, PLR, and NLR are found to be associated with prolonged hospitalization and ICU stay and delayed oral feeding following THE for Siewert types II and III AEG. We hope by this series, to have set, at least one preliminary cornerstone, in the creation of a prognostic model, capable of assessing the need for an intraoperative jejunostomy placement, in patients undergoing esophagectomy for distal esophageal carcinoma.

Complications of feeding jejunostomy placement: a single-institution experience.

Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable. A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30days) and in a long-term follow-up (> 30days). The Chi-square test was used to compare rates of complications according to tube size. Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications. The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.

Bevacizumab does not increase risk of perforation in patients undergoing percutaneous endoscopic gastrostomy or jejunostomy placement.

Bevacizumab is a humanized anti-vascular endothelial growth factor monoclonal antibody used in the treatment of cervical cancer, ovarian cancer, colorectal cancer, lung cancer, renal cell cancer, and recurrent glioblastomas. Its approval by US FDA was issued with a black box warning that its use has been associated with a risk of gastrointestinal (GI) tract perforation and that it should be discontinued in patients who have experienced such. The reported incidence of GI perforation in those receiving bevacizumab is as high as 3%. However, the incidence of GI perforation in those receiving bevacizumab undergoing GI endoscopic procedures has not been well studied. A retrospective, single-center observational study was conducted at Memorial Sloan Kettering Cancer Center (MSKCC) between 2011 and 2018. All patients who underwent upper GI endoscopy with percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) tube placement and received bevacizumab within 6months of their endoscopic procedure were included. We identified 176 patients who underwent PEG or PEJ tube placement and received bevacizumab within 6months. Eighty-one percent of patients were female (n = 144) and the median age was 61years. Prior to endoscopic procedures, patients received a median of seven doses of bevacizumab. Patients received bevacizumab from 170days before to 170days after their endoscopic procedures (median 44days). No GI perforations were observed during or after the time of the endoscopic procedures. Our study demonstrated that receiving bevacizumab within 6months prior to their endoscopic procedure was not associated with an increased risk of GI tract perforation and thus not an absolute contraindication to proceeding with PEG and PEJ tube placement in these patients.

Jejunostomy at the time of esophagectomy is associated with improved short-term perioperative outcomes: analysis of the NSQIP database.

Adequate preoperative and perioperative nutrition has been shown to improve outcomes for patients undergoing esophagectomy. The most effective way to provide enteral nutrition for patients after esophagectomy is via jejunostomy tube. There is an open debate whether a feeding jejunostomy tube is necessary at the time of esophagectomy. This study evaluated short term surgical outcomes for patients undergoing esophagectomy with and without concurrent jejunostomy tube placement. Esophageal cancer patients were identified from the NSQIP database who underwent esophagectomy between 2005 through 2016. Patients were classified into 2 cohorts: patients with concurrent jejunostomy tube placement and those without jejunostomy placement at the time of esophagectomy. Clinical and demographic data was collected. Differences in short term outcomes were assessed by univariate and multivariable analysis, including prolonged hospital stay (>30 days), in-hospital mortality, and 30-day mortality for both cohorts. We identified 8,632 patients that underwent esophagectomy for esophageal cancer with 80% males and mean age of 63.2±10.6 years. Twenty percent (n=1,723) had preoperative weight loss in the 6-month period preceding surgery. Forty-five percent (n=3,900) patients had jejunostomy placement at the time of esophagectomy. Overall, the rate of prolonged hospital stay (P=0.006), in-hospital mortality (P<0.001) and 30-day mortality (P<0.001) were significantly higher in patients without concurrent jejunostomy in both univariable and multivariable models. This study demonstrates that patients with jejunostomy placement at the time of esophagectomy have improved short term perioperative outcomes.

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.

Comparison of Laparoscopy vs Mini-Laparotomy for Jejunostomy Placement in Patients with Gastric Adenocarcinoma

Comparison of Laparoscopy vs Mini-Laparotomy for Jejunostomy Placement in Patients with Gastric Adenocarcinoma