Jejunostomy Tube Research Articles

Percutaneous Jejunostomy: Repeat Access at the Healed Site of Prior Surgical Jejunostomy with US and Fluoroscopic Guidance

PurposeTo evaluate the safety and efficacy of ultrasound (US)- and fluoroscopy-guided jejunostomy tube placement in patients with a history of surgical jejunostomy. Materials and MethodsBetween June 2003 and June 2012, percutaneous US-guided jejunostomy placement was attempted 28 times in 26 patients with a history of surgical jejunostomy (14 men and 12 women). Retrospective chart review was performed to determine procedural success, complications, and interval between original jejunostomy and new tube placement. Clinical outcomes were evaluated with a mean follow-up period of 110 days (range, 3–631 d; median, 68 d). ResultsSuccessful tube placement was achieved in 26 of 28 attempts (92%). The mean time between removal of the original surgical jejunostomy and percutaneous placement of the new tube was 278 days (range, 3 d to 8 y; median, 88 d). A single minor complication involved a tube site infection 4 days after the procedure. There were no major complications. Mean procedure time was 49 minutes (range, 15–125 min; median, 45 min). ConclusionsPercutaneous jejunostomy access can be reliably and safely reestablished with US and fluoroscopic guidance in patients with a history of surgical jejunostomy.

Clinical Guideline: Management of Gastroparesis

This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.

Feeding jejunostomy during Whipple is associated with increased morbidity

BackgroundPlacement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD. Materials and methodsThis is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients. ResultsThirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis. ConclusionAlthough FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.

Trocar Guided Laparoscopic Feeding Jejunostomy

Several techniques of laparoscopic feeding jejunostomy have been described. Most of them require costly commercial kits. Here we present a novel, simple, low-cost method for laparoscopic jejunostomy tube placement. This technique involves 4 ports. A left lateral "guide" trocar is used as a landmark for tube placement. A jejunal loop is selected and 4 vicryl sutures are placed in a diamond shape on the antimesenteric side of the intestine and left untied. These 4 stitches are extracted using a transabdominal suture grasper inserted through 4 small incisions around the left lateral guide trocar. After an enterotomy is made in the center of these 4 stitches using cautery device, the left lateral trocar is removed and a 12 Fr Foley catheter is inserted in the trocar site and introduced into the bowel. The 4 stitches are pulled toward the abdominal wall and gently tied without additional suturing. Eight patients who underwent this procedure between 2007 and 2009 were reviewed. The procedure was successful in all patients. The median operative time was 70.5 minutes. There were no postoperative complications with respect to infection, bleeding, or bowel obstruction, and no perioperative mortality. Our trocar-guided approach for laparoscopic feeding jejunostomy placement is a simple, cost-effective, safe, and effective method.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.

Double-balloon enteroscopy as a rescue technique for failed direct percutaneous endoscopic jejunostomy when using conventional push enteroscopy (with video)

s A e D f z t t d i Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement is indicated in patients who require prolonged enteral feeding but are not suitable candidates for PEG or when attempted PEG placement fails. Although PEG with transgastric jejunal tube extension (PEG-J) is another option, the delivery rate of enteral feeds is limited by the narrowbore extension tube, which is also prone to frequent obstruction and migration back into the stomach. Furthermore, PEG-J may not decrease the risk of recurrent aspiration pneumonia as has been shown with DPEJ.3 However, DPEJ is technically challenging, with lower rates of successful placement than PEG. DPEJ is usually performed by using colonoscopes or push enteroscopes,

Laparoscopic Button Loop Feed Jejunostomy

Purpose: The purpose of this procedure is to provide a minimally invasive feeding access technique in patients in whom oral or intragastric nutrition is not an option. Surgically placed feeding jejunostomies allow patients to receive postpyloric enteral nutrition in a tolerable and safe manner. At our institution, we designed a minimally invasive technique to place feeding jejunostomies that is not only simple but also more importantly safe and effective. This 2-minute video demonstrates the technique for placing a button loop-feeding jejunostomy in the pediatric population. Methods: The surgical technique entails accessing the abdomen with a 3/5-mm scope at the umbilicus, placing a 12-mm port in the right side of the abdomen, and placing a second working 3/5-mm port in the right-lower quadrant. The right side of the abdomen is chosen as most of our patients have a gastrostomy tube in the left-upper abdomen. The patient is placed in reverse trendelenberg, and the small bowel is displaced into the lower abdomen. The transverse colon is elevated, allowing identification of the ligament of treitz. Approximately 15 to 20 cm from the ligament of treitz, the jejunum is exteriorized through the 12-mm-port site. The jejunum is folded onto itself. Guy sutures are placed distally. A purse-string suture is placed at the apex. An enterotomy is made. An endoscopic stapler is inserted into the limbs of the jejunum. If an endoscopic stapler is used, two staple fires should be utilized to ensure an adequate channel length. If a gastrointestinal anastomosis stapler is utilized, a single cartridge may be utilized. An extracorporeal side‐to‐side anastomosis is performed. A MicKey button is inserted, and the purse-string suture is secured. Anchor sutures are placed onto the peritoneum and secured in the same manner as a Stamm gastrostomy tube. Results: Tube feeds are initiated in 8–12 hours and increased to goal volume within the first 24 hours. The first tube change may be performed on the same schedule as that of a Stamm gastrostomy tube. Conclusion: We believe that our laparoscopically placed loop-feeding jejunostomy tube is a safe and effective means of establishing a permanent feeding access in patients who are unable to tolerate oral or intragastric feeds. This technique may reduce the risks of bowel obstruction and intussusceptions. It allows for safer access by our interventional radiology colleagues in the event of premature tube dislodgement. It also obviates tube complications such as tube migration and occlusion. No competing financial interests exist. Runtime of video: 2 mins

PMO-018 Dedicated specialist dietetic input improves outcomes for UGI surgical cancer patients

IntroductionUpper GI (UGI) cancer patients are at high risk of malnutrition increasing risk of complications post-operatively. Surgeons and Oncologists at Ninewells Hospital, Dundee funded an UGI Oncology Dietitian who oversaw...

PMO-086 How useful is feeding jejunostomy in upper gastro intestinal cancer surgery—a retrospective review

IntroductionA retrospective review of outcome of 100 consectutive open feeding jejunostomies performed as part upper GI cancer surgery in our Centre in the last 3 years.Methods100 consecutive patients undergoing open...

Staged operation for synchronous quintuple cancer in the oral cavity, hypopharynx, and esophagus

Esophageal cancer is frequently associated with head-and-neck cancer. It is difficult to select treatment modalities for synchronous multiple cancers in the upper aerodigestive tract. A 58-year-old woman had synchronous quintuple cancer of the upper aerodigestive tract and was in a poor nutritional state due to oral pain and dysphagia. Clinical stages of cancer in the oral cavity, hypopharynx, cervical esophagus, middle thoracic esophagus, and lower thoracic esophagus were IVA (cT4a N2b M0), I (cT1 N0 M0), IA (cT1 N0 M0), IA (cT1 N0 M0), and IIA (cT3 N0 M0), respectively. After preoperative chemoradiotherapy, curative resection of oral cavity cancer and a tube jejunostomy were performed. Then, pharyngolaryngectomy, total esophagectomy, and pharyngostomy were performed. Finally, after additional radiotherapy to the oral cavity, pharyngogastrostomy with gastric tube and microvascular anastomosis were performed. The patient achieved oral intake and is in good condition and has at this writing remained recurrence free for 26 months. This report suggests that even if there are multiple cancers, adopting multimodal treatment strategies for controlling each cancer may lead to a chance to obtain a complete cure.

A Modified and Simplified Technique for Laparoscopic Tube Jejunostomy

A Modified and Simplified Technique for Laparoscopic Tube Jejunostomy

Profound Gastroparesis after Bilateral Posterior Inferior Cerebellar Artery Territory Infarcts (P01.030)

Objective: To describe a case of acute gastroparesis as a result of medullary infarction. Background Function of the gastrointestinal system is partially dependent upon the integrity of the lower brain stem. While dysphagia commonly results from strokes of varying locations, acute dysfunction of other segments of the alimentary canal from stroke is not a well-described phenomenon. Design/Methods: Case report. Results: A 65 year old man with a history of diabetes mellitus without previous gastrointestinal difficulty presented with sudden onset vertigo, nausea, vomiting, a left Horner9s syndrome and hemiataxia, as well as gait ataxia. Magnetic resonance imaging (MRI) revealed an acute infarction in the midline cerebellum bilaterally and the left posterior caudal medulla, all within the right and left posterior inferior cerebellar artery (PICA) territories. Over the following week, the persistent nausea, vomiting, and vertigo gave way to severe nausea and vomiting exclusively after eating, accompanied by instantaneous satiety. Brain imaging demonstrated acute infarction of the midline cerebellum bilaterally and the left posterior caudal medulla. Serial cranial CT scans revealed minimal changes; a contrast-enhanced abdominal CT and endoscopy showed severe gastric distention but no anatomical obstruction of the gut. A gastric emptying study demonstrated 99% retention of the radiolabled meal on serial scintigraphy after 2, 3, and 4 hours post-ingestion, with minimal activity seen in the duodenum, consistent with severe gastroparesis. His symptoms were refractory to medical management, and he required a jejunostomy tube for 8 weeks as his oral intake gradually improved. Conclusions: Acute, isolated gastroparesis without gastrointestinal pathology can result from medullary infarctions. A possible explanation may be infarction or edema particularly affecting the pars centralis of the nucleus of the tractus solitarius. Preexisting diabetes mellitus may also have been a predisposing factor. Disclosure: Dr. Liff has received personal compensation for activities with E-Rewards Medical. Dr. Labovitz has nothing to disclose. Dr. Robbins has nothing to disclose.

Efficacy and Complications of Nasojejunal, Jejunostomy and Parenteral Feeding After Pancreaticoduodenectomy

BackgroundEuropean nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce. MethodsRetrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake. Results129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (P=0.99), in-hospital stay (P=0.83) and mortality (P=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days, P=0.15) and incidence of delayed gastric emptying (P=0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days, P=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%, P=0.02). ConclusionNone of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.

A novel technique of permanent self-catheterizable feeding jejunostomy

Long-term/permanent jejunal feeding in children and adults is prone to significant complications, such as leakage, skin excoriation, and difficulty in reinsertion after dislodgement of the jejunostomy tube. Our innovative jejunostomy technique uses a pedicle segment of jejunum, which is retubularized using the principle of Monti. The jejunal segment is reinserted through a submucosal tunnel back into the jejunum. The other end is brought out onto the abdominal wall. The technique achieves a continent catheterizable jejunal stoma for enteral feeding.

Abstract No. 108: Percutaneous insertion of primary jejunostomy tubes: comparison to percutaneous gastrojejunostomy tubes

Abstract No. 108: Percutaneous insertion of primary jejunostomy tubes: comparison to percutaneous gastrojejunostomy tubes

Endoscopist’s approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist's approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Small bowel intussusception in a child following feeding jejunostomy: A rare case with review of literature

Jejuno-jejunal intussusception is a rare complication of feeding jejunostomy tube placement. A case of one year old child who underwent gastric pull-up for complicated tracheo-esophageal fistula had jejuno-jejunal intussusception induced by Witzel's feeding jejunostomy tube; is discussed with review of literature.

Unusual Presentation of Ascaris lumbricoids

Ascariasis is the most common helminthic infestation in India. It affects mainly children of low socioeconomic status whose standards of public health and personal hygiene are at the lowest. Ascaris lumbricoides infestation can lead to serious complications because of the wander lust of the worms. Complications such as intestinal obstruction, volvulus, gangrene, pancreatitis, biliary obstruction, cholangiohepatitis and liver abscess have been reported to occur. We report a case where ascaris was seen blocking jejunostomy tube.

Post-esophagectomy chylothorax successfully treated with the combination of thoracic duct clipping and octreotide administration

We herein describe the case of a 61-year-old man with stage II esophageal cancer who experienced chylothorax after esophagectomy. He was successfully treated with thoracic duct clipping and octreotide administration. Previously the patient had had a head and neck cancer treated with multimodality treatment: neoadjuvant chemoradiation therapy, operation, and adjuvant CRT. Then, esophagectomy with lymph node dissection without resection of the thoracic duct was performed via a right thoraco-abdominal approach. On postoperative day 1, enteral nutrition was started. On day 5, the chest tube drainage increased to 2000 ml per day. On day 7, the drainage fluid increased to 3000 ml per day, and its color turned cloudy white. We then performed lymphoscintigraphy and diagnosed the patient as having chylothorax. Immediately we administered intermittent subcutaneous octreotide 100 μg × 3 per day; however, it could not stop the leakage. On day 13, we performed an operation: a fat-rich supplement was administered through the jejunostomy tube before the operation, the thoracic duct injury was readily identified, and we clipped the thoracic duct in the superior mediastinum, followed by 300 μg per day octreotide treatment. On day 16, however, 400 ml per day of chyle leaked from the drain again, and we increased the dose of octreotide to 600 μg per day. On day 18, the drainage stopped, and the patient was discharged on day 38. Octreotide administration combined with surgical treatment should be considered as a treatment option for chylothorax, which is a rare complication of esophagectomy.

New successful one-step surgical repair for apple peel atresia

New successful one-step surgical repair for apple peel atresia Mahmoud MachmouchiDepartment of Pediatrics, Royal Commission Hospital, Jubail, Saudi ArabiaAbstract: A new successful surgical approach in two identical twins delivered with intestinal atresia, &ldquo;apple peel&rdquo; type is reported. This technique consists of: (1) an end-to-end oblique primary anastomosis with single layer inverted 5/0 Vicryl&reg; sutures (Ethicon, Inc, Somerville, NJ); (2) proximal tube jejunostomy using Foley catheter, size 10 French, inserted through a stab wound in the left upper quadrant and entering the proximal dilated loop at about 10 cm proximal from its blind end (site of anastomosis); and (3) transanastomotic stenting using feeding tube, size 6 French, exteriorized in conjunction with the Foley catheter and reaching the lumen of the distal loop for more than 20 cm. The postoperative course was uneventful and progressive oral feed became ad libitum around day 40 postoperative. This procedure is simple, performed in one stage, and responds to the most obligatory requirements of this congenital malformation.Keywords: proximal jejunal atresia, intestinal atresia, surgical repair, anastomosis