Jejunostomy Tube Research Articles

Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis

Loop ileostomy is a suitable procedure for transitory faecal diversion after colorectal or coloanal anastomosis. We describe here an easy alternative technique for ileostomy construction that does not require reintervention for the closure. In twenty patients undergoing anterior resection of the extraperitoneal rectum with colorectal and/or coloanal anastomosis, loop ileostomy was performed using a modified jejunotomy tube inflated with 10 ml of normal saline. The tube was deflated on the eighth post-operative day and removed on day 11 after a radiological contrast enema of the anastomosis. Radiological control carried out on day 11 evidenced a premature dislocation of the jejunostomy tube in 1 patient, thus the tube was correctly removed without any complications. In another patient a delayed closure of the ileo cutaneous fistula was recorded that required simple medication over 15 days in the out patient clinic. No signs of anastomotic leakage, either clinical or radiological were evidenced. We have described here a safe alternative technique for loop ileostomy with negligible complications related to construction as demonstrated in our results.

Sonographically Guided Jejunostomy Replacement

Enteral feeding through jejunostomy is an established nutritional support for patients with esophageal cancer. Mechanical problems are common during long-term enteral nutrition, and jejunostomy tube dislodgment is one of the most flequent. 1 Dislodged jejunostomy tubes should be replaced as promptly as possible to maintain feeding access and require meticulous attention to obviate surgical substitution. Replacement under fluoroscopic guidance is considered safe and simple, and it is the preferred method in several centers; however, surgery remains the last option when endoscopic and radiologic methods are not successful. 2 Here we report a case of percutaneous sonographically guided needle jejunostomy after fluoroscopically guided replacement failures.

Use of Universal Catheter Access Port for Management of Leaking Tubes in the Palliative Care Setting (725)

1.Discuss photos demonstrating use and application of universal catheter access port.2.Discuss photos of chemical damage/fungal rash on peri-tube skin secondary to leakage of effluent.3.Compare photos showing skin healing after treatment. I. Background. The use of tubes today is commonplace, especially in the palliative care setting. These tubes are used to help relieve symptoms, provide nutrition, and bypass obstructions, whether it is a gastrostomy, jejunostomy, biliary, suprapubic, or nephrostomy tube. Unfortunately many of these tubes leak and are unable to be replaced at the end-of-life. Painful chemical irritation and fungal infections can occur around a tube site due to leakage. II. Case Description. Photos will be used with written descriptions. Poster will demonstrate comparisons of skin integrity before and after using Universal Catheter Access Port. Also included will be examples of the versatility of this device (eg, containment of drainage from a tumor surrounding a suprapubic tube, containment of leakage around two Jackson-Pratt tubes). III. Conclusion. Our outcomes will show:1.rapid improvement of skin integrity as a result of effectively diverting effluent away from the skin;2.relief of painful symptoms;3.provides a means of visualizing and measuring output; and4.device is versatile and cost-effective.

Esophageal Hiatal Hernia in Three Exotic Felines—Lynx lynx, Puma concolore, Panthera leo

Hiatal hernia was diagnosed in three exotic felines-lynx (Lynx lynx), cougar (Puma concolore), and lion (Panthera leo). All cats had a history of anorexia. Thoracic and abdominal radiographs showed evidence of a soft tissue mass within the caudal mediastinum suggestive of a hiatal hernia in all animals. A barium esophagram was performed in one case. All animals underwent thoracic or abdominal surgery for hernia reduction. Surgical procedures included: intercostal thoracotomy with herniorrhaphy and esophagopexy (lynx and cougar), and incisional gastropexy (lion). Concurrent surgical procedures performed were gastrotomy for gastric foreign body removal and jejunostomy tube placement. Clinical signs related to the hiatal hernia disappeared after surgery and recurrence of signs was not reported for the time of follow-up.

Traumatic Transection of Pancreas at the Neck: Feasibility of Parenchymal Preserving Strategy.

BackgroundTo assess the feasibility and safety of a pancreas preserving operative technique in the management of isolated complete pancreatic neck transection following blunt abdominal trauma.MethodsTwo patients with isolated blunt fracture of the pancreatic neck underwent pancreas preserving procedure comprising of oversewing of the proximal pancreas and Roux-en-Y pancreatico jejunostomy to the distal remnant. A feeding jejunostomy tube was placed for postoperative nutritional support in these patients. Both patients received subcutaneous octreotide 300 µg/day.ResultsTheir ages ranged from 15 years to 20 years, mode of injury was bicycle handle-bar injury (n = 2). Both had pancreatic transection at neck in the line of superior mesenteric vessels. One had ascites. These patients had pancreas parenchyma preserving surgery – internal drainage of the left remnant in a Roux-en-Y jejunal loop. The postoperative course was uneventful in these and both are well on follow-up.ConclusionsPancreas preserving strategy – suture of head side of pancreas and an internal drainage of left remnant with a Roux-en-Y jejunal loop is feasible and safe and should be considered in selected cases. Substantial amount of normal pancreatic parenchyma is preserved.

Care of the Child Assisted by Technology

Care of the Child Assisted by Technology

Usefulness of an ultrathin endoscope in recanalization of a disrupted fistulous tract following percutaneous endoscopic gastrostomy or jejunostomy

A disrupted fistulous tract is a rare complication associated with the replacement of a gastrostomy or jejunostomy tube [1]. It is important to confirm that the replacement tube is accurately positioned in the same site as the previous one. Although adverse events following fistula disruption have been reported [2] [3], little is known about how the fistula can be successfully recanalized.

Long Term Placement of Self-expanding Plastic Stents is Safe for Benign Esophageal Disease

Purpose: Removable self-expanding plastic stents (SEPS) are used for the short-term treatment of benign esophageal diseases including strictures and esophageal fistulae. The purpose of this study was to determine the efficacy and safety of SEPS left in place for greater than 90 days for benign esophageal disease. Methods: Patients receiving a SEPS from 2003-2009 for benign esophageal disease at a single university center were retrospectively identified using an endoscopic database (Provation Medical, Minneapolis, MN). Patients with a stent left in place for more than 90 days were included in this study. Indication for stent placement, stent size, duration of stent placement, follow-up endoscopy and imaging studies, and the efficacy of treatment were collected. Results: Nine patients were included. Indication for stent was benign stricture refractory to dilation (8) or esophageal fistula (1). Cause of the stricture was esophagectomy (7), esophageal Castleman's disease (1). Median age was 53.4 years; 8 were males. SEPS placement was successful in all patients. The median stricture length was 2 cm (range 1-8 cm). Stents were left in place for 3-34 months (median 11). In 7, the stent was removed without difficulty. Six received a second stent for stricture recurrence. The most commonly used stent had a diameter of 18mm. Follow-up EGD was performed in eight patients. One patient had stent placement confirmed after 23 months by a CT scan. Stent migration occurred in 3 patients. The most common endoscopic finding was granulation tissue adjacent to the proximal or distal stent margin. One stent migrated proximally into the proximal esophagus, causing ulceration and stricture requiring dilation. In another patient with proximal stent placement for 27 months, a trachea-esophageal fistula developed after stent removal, requiring placement of a new stent and jejunostomy tube. Conclusion: SEPS can be safely left in place for greater than 3 months in some patients with benign esophageal disease refractory to other treatments. Complications developed in those with proximal esophageal placement. Stent migration was seen in 3/9 (33.3%) of patients.Table

Gastroparesis: Current Concepts and Management

Delayed gastric emptying in the absence of mechanical obstruction is referred to as gastroparesis. Symptoms that are often attributed to gastroparesis include postprandial fullness, nausea, and vomiting. Although tests of gastric motor function may aid diagnostic labeling, their contribution to determining the treatment approach is often limited. Although clinical suspicion of gastroparesis warrants the exclusion of mechanical causes and serum electrolyte imbalances, followed by empirical treatment with a gastroprokinetic such as domperidone or metoclopramide, evidence that these drugs are effective for patients with gastroparesis is far from overwhelming. In refractory cases with severe weight loss, invasive therapeutics such as inserting a feeding jejunostomy tube, intrapyloric injection of botulinum toxin, surgical (partial) gastrectomy, and implantable gastric electrical stimulation are occasionally considered.

The expanding role of interventional radiology in head and neck surgery

Interventional radiology is defined by the Society of Interventional Radiology as ‘the delivery of minimally invasive, targeted treatments, performed using imaging for guidance’. Although the principles of angiography for diagnosis have existed since the 1920s, and today remain a well-established modality for the diagnosis of many common conditions, it was not until the 1960s that the American Charles Dotter, and other pioneers, extended these techniques from diagnosis to treatment.1 Their foresight, together with ever-increasing technological capability, allowed the use of transluminal angioplasty for the treatment of peripheral vascular disease and led Dotter to say, in 1964, that ‘it should be evident that the vascular catheter can be more than a tool for passive means for diagnostic observations: used with imagination it can become an important surgical instrument’.2,3 Thus, interventional radiology as a specialty was born. Work on the cerebral vasculature began in the 1970s, largely for neurosurgical conditions. It is perhaps not surprising that the initial, and still best known, uses of interventional radiology were for the highly accessible vascular system, and for the type of non-vascular conditions that offered poor surgical access, such as in neurosurgery. More recently, interventional radiology techniques have been applied to head and neck cancer patients, initially with the use of detachable balloon occlusion in patients with laryngeal cancer and impending carotid artery rupture. From this, the range of applications of interventional radiology in the extra-cranial head and neck has continued to evolve and expand. These applications include line placement, foreign body removal, placement of feeding tubes (primary gastrostomy, gastrojejunostomy or jejunostomy tubes), and oesophageal or bronchial dilatation and stenting. The main focus of this review is on the vascular applications of interventional radiology in the head and neck, which can be divided into three main categories: management of acute haemorrhage (e.g. epistaxis, carotid blowout); management of vascular lesions (e.g. tumours, arterio-venous malformations); and venous sampling.

457 Gastric Pacing Can Eliminate Dependency On Supplemental Nutrition and Improve Medically Refractory Gastroparesis

INTRODUCTION: Gastric stimulation has been shown to improve the symptoms of medically refractory gastroparesis. With enough symptomatic improvement, patients should be able to decrease or eliminate their dependency on supplemental nutrition (parenteral or enteral) in the post-operative period. MATERIALS AND METHODS: This is a review of a single surgeons operative experience from 9/02 to 7/08. Patients with a diagnosis of diabetic or idiopathic gastroparesis that had a gastric pacer placed were selected for analysis. Chart review included age, gender, weight, symptom improvement, and the requirement of additional nutritional supplementation at baseline, six, and 12 months. RESULTS: Fifty-two patients had interrogation and programming of the gastric pacer (Enterra) at time of implantation. As part of follow-up, patients were assessed for symptom improvement and were adjusted appropriately if no improvement was seen. Patients included eight males and 44 females. The average age was 38 years (range 20-87). Thirty-one had a pre-operative, 6 month, and 12 month weight recording. Average weight was 151.9 lbs, 153.2 lbs, and 155.1 lbs at those respective times. In 47 patients with a mean follow-up of 19 months, 34 (72%) reported improvement in symptoms, nine (19%) reported no improvement in symptoms, and four had initial resolution of symptoms but return to baseline at last followup. Preoperatively, 10 patients were receiving jejunal feeds (TF) and two were receiving total parenteral nutrition (TPN). Subsequently after device implantation, seven patients at six months and an additional three at one year were off all forms of supplementation and receiving nutrition solely by mouth. No statistically significant weight change was seen in this group. Seven patients had a jejunostomy tube placed at the time of device implantation for subsequent enteral feeds. Three patients at six months had enteral feedings stopped and the remaining four continued tube feeds at one year. No patient in this group had an infectious complication secondary to concomitant gastric stimulator and jejunal tube placement. One Enterra system was replaced due to device malfunction, two revised secondary to generator malposition, and one removed due to lead erosion. CONCLUSIONS: The majority of patients demonstrated weight stability after gastric pacer placement. 72% of patients reported improvement in symptoms. Patients receiving supplemental nutrition preoperatively showed decreased reliance on enteral feeds or TPN after gastric stimulation. Concomitant jejunal tube and gastric pacer placement did not demonstrate a higher infectious complication rate.

Benefits Versus Risks: A Prospective Audit

The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy. The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal. Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 +/- 22.00 days (range 0-46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 +/- 16.24 vs. 14.69 +/- 19.04 days; p = 0.000) and postoperative complications (26.67 +/- 25.56 vs. 14.52 +/- 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy. Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.

Endoscopic identification of the jejunum facilitates minimally invasive jejunostomy tube insertion in selected cases

Percutaneous endoscopic gastrostomy (PEG), direct percutaneous endoscopic jejunostomy, and laparoscopic feeding tube insertion are established techniques for placing a feeding tube. However, these techniques may be difficult or contraindicated after previous gastric or upper abdominal surgery. A total of 10 patients underwent minimally invasive jejunostomy tube insertion via endoscopic identification of the jejunum. The indications for the procedure were dysphagia, poor nutritional status, prolonged intensive care unit (ICU) admission, and gastroparesis. Eight of the patients had undergone previous upper abdominal surgeries and were rejected for either PEG or direct percutaneous jejunostomy. With the patients under general anesthesia, esophagogastroduodenoscopy was performed. The jejunum was identified and intubated. A small abdominal incision (1 in.) was made. The proximal jejunum was identified easily by the light and digital palpation of the endoscope. The jejunum was delivered in the wound, and the jejunostomy tube was inserted using Witzel's technique. The wound was closed. All the patients tolerated the procedure well. The mean time for the procedure was 29 +/- 13 min. There was no mortality related to the procedure and no complications. Jejunal feeding started on the first postoperative day. The use of intraoperative endoscopy facilitated identification of the jejunum. Easy, safe, and quick, the procedure saved the patient a formal laparotomy and extensive manipulation.

Replacement of a Feeding Tube Through the Gastric Tube in Patients After Esophagectomy With Retrosternal Reconstruction

We present our technique of endoscopic replacement of the jejunostomy through the stomach conduit in patients after esophagectomy with retrosternal reconstruction. After an upper gastrointestinal tract endoscopy was performed, the stomach conduit was sufficiently inflated with air and the site of the previously removed gastric tube was confirmed by the puncture using 23 G needle. After an approximately 6-mm incision was made under local anesthesia, a 4-mm peel-off introducer sheath was advanced into the stomach conduit under endoscopic control. A 3-mm jejunostomy tube was inserted through the sheath and placed into the jejunum using the endoscopic guidance. Using endoscopy, the jejunostomy tube was confirmed to be placed without bending. Between 1998 and 2006, subtotal esophagectomy with retrosternal cervical esophagogastrostomy was performed in 48 patients. All patients were inserted with at least either jejunostomy tube or decompression tube through the stomach conduit. Among them, 11 patients (23%) were performed percutaneous replacement jejunostomy through the stomach conduit. There were 9 men and 2 women whose mean age was 67 years (range: 59 to 76 y). Replacement of the jejunostomy tube was successful in all patients. The procedure required about 30 minutes. There were no deaths and no procedural complications. After 24 hours, the tube was used for enteral feeding. No late complication occurred in our cases. We believe that the endoscopic percutaneous approach described in this report is safe and effective in patients after esophagectomy with retrosternal reconstruction.

Risk of Immediate and Delayed Complications with Percutaneous Gastrostomy and Jejunostomy Tubes in Patients Receiving Bevacizumab

Background: Bevacizumab is a humanized monoclonal antibody targeting the vascular endothelial growth factor. Although, it is generally well tolerated, gastrointestinal (GI) complications include perforation and bleeding. There is no data on the safety of performing a percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ) in patients receiving Bevacizumab. Objective: To determine the risk of immediate and delayed GI perforation and bleeding following PEG and PEJ tube placement in patients who received Bevacizumab within 60 days of the procedure. Methods: A retrospective chart review of all patients who underwent a successful PEG or PEJ between January 2003 and August 2008, and also received Bevacizumab within 60 days of the procedure was done. Data included demographics, type of cancer, prior treatment, indication for PEG/PEJ, timing of Bevacizumab and post-procedural complications. Results: 83 patients were identified. Underlying cancers included: head & neck (35), colorectal (19), ovarian (11), other GI (13) and others (5). Forty six (55%) were men and 37 (45%) were women. The mean age was 55 years (range, 21-80). Forty three (52%) underwent a major abdominal surgery prior to the procedure and the primary tumor was resected in 46 (55%) of them. There were 77 (92%) gastrostomies and 6 (8%) jejunostomies. The indication was enteral feeding in 46 (55%) and GI decompression in 37 (45%). Thirty nine had their procedure 13.6 +/- 12 days before starting Bevacizumab, 41 had their PEG/PEJ placed 31 +/- 30 days after stopping Bevacizumab and 4 while receiving Bevacizumab. There were 6 complications, 3 major and 3 minor: GI bleeding requiring transfusion (2), pneumatosis intestinalis and sepsis (1), abdominal pain (2), and a buried bumper (1). The bleeding was 105 and 30 days post procedure and Bevacizumab discontinuation respectively in the first patient and 15 and 60 days in the second patient. Neither was a procedure related complication nor was the PEG site a source of bleeding. One was bleeding from tumor and the other from hemobilia. One patient developed pneumatosis of the GI tract, along with air in the portal venous system, 2 and 17 days after PEJ placement and stopping Bevacizumab respectively. This was the only major procedure related complication and the patient improved with antibiotics and observation. Of the 3 minor, 2 had persistent abdominal pain that resolved spontaneously and 1 was a buried bumper that required PEG revision. Conclusion: Placement of PEG or PEJ tubes in patients receiving Bevacizumab within 60 days of the procedure is safe. Also, use of Bevacizumab is safe in patients who underwent a recent gastrostomy or jejunostomy.

Percutaneous Endoscopic Jejunostomy and Jejunal Extension Tube through Percutaneous Endoscopic Gastrostomy: A Retrospective Analysis of Success, Complications and Outcome

Background: Percutaneous access to the jejunum is an important approach if gastrostomy feeding is not possible. Objective: To analyze success, short- and long-term complications (STCs, LTCs) in patients with percutaneous endoscopic jejunostomy (PEJ) and jejunal access through percutaneous endoscopic gastrostomy (Jet-PEG). Methods: A retrospective analysis of endoscopically placed PEJs and Jet-PEGs. Success rates, mortality, STCs and LTCs were investigated for risk factors comprising demographic data, underlying disease, previous surgery and experience of the endoscopist. Results: 205 PEJ and 58 Jet-PEG placements were included in the study. PEJs and Jet-PEGs were successfully placed in 65.4 and 89.7%, respectively. Billroth II surgery predisposed in favor of a significantly higher success rate for PEJ placement (p = 0.014, OR = 2.27). Inexperienced examiners have a significantly (p = 0.040) lower success rate for tube insertion than examiners with a medium level of experience. STCs and LTCs occurred evenly in PEJ and Jet-PEG patients. Dislocation of the tube occurred significantly more frequently in Jet-PEG patients (33.3%, p = 0.005). Aspiration was most common for bedridden patients. Conclusion: PEJ has a significantly lower success rate for insertions, but fewer LTCs. The experience of the endoscopist correlates with the success rate of tube insertion.

Successful transgastric drainage of a large mucinous adenocarcinoma of the stomach for palliation of malignant gastric luminal obstruction

Six months prior to being seen at our institution, a 30year-old man presented with sudden onset of large volume ascites. The fluid cytology revealed malignant cells. An exploratory laparotomy revealed massive peritoneal involvement with metastatic mucinous adenocarcinoma, signet ring type. An ulcerated neoplasm at the gastro-esophageal junction was found on esophagogastroduodenoscopy; it was biopsied and demonstrated moderately differentiated adenocarcinoma. CTscan showed thickening of the gastric wall. He received several rounds of chemotherapy over several months. One month prior to the patient being seen at our institution, a CTscan showed compression of the stomach lumen by a large cystic mass arising from the wall of the stomach (Fig. 1). He presented to Mayo Clinic with anorexia, nausea, and postprandial vomiting of both solids and liquids, and had required 2 hospitalizations for dehydration with weight loss of 50 pounds over 2 months. Gastroenterology was consulted for advice on feeding options. A PEG or percutaneous endoscopic jejunostomy tube was not possible because of the large volume ascites and gastric compression. A nasojejunal tube was declined by the patient. Transmural drainage was offered as a novel approach for palliation. An EUS was done to confirm that the lesion was composed primarily of liquid and amenable to drainage. The EUS showed a large cystic mass abutting the greater curvature of the stomach, consisting mostly of nonviscous fluid with a small solid component (Fig. 2). It was determined, by the endoscopic appearance, that the lesion was fluid, and a primary aspirate was not performed. The presence of viscous contents might have necessitated the use of lavage, though the 10-mm stent would have been adequate to drain viscous fluid, as opposed to 10F plastic stents.

Technique of Open Ivor Lewis Esophagectomy

Technique of Open Ivor Lewis Esophagectomy

Treatment of Refractory Gastroparesis: Gastric and Jejunal Tubes, Botox, Gastric Electrical Stimulation, and Surgery

Refractory gastroparesis is a challenging disorder for gastroenterologists, internists, surgeons, and all health care professionals involved in the care of these patients. It should be managed by a stepwise algorithm beginning with dietary modifications, then prokinetic and antiemetic medications, measures to control pain and address psychological issues, and endoscopic or surgical options in selected patients, including placement of feeding jejunostomy tubes.

Novel cost-effective method of laparoscopic feeding-jejunostomy

A feeding jejunostomy tube placement is required for entral feeding in a variety of clinical scenarios. It offers an advantage over gastrostomies by eliminating the risk of aspiration. Standard described laparoscopic methods require special instrumentation and expensive custom-made tubes. We describe a simple cost-effective method of feeding jejunostomy using regular laparoscopic instruments and an inexpensive readily available tube. The average operating time was 35 min. We had no intra-operative complications and only one post-operative complication in the form of extra-peritoneal leakage of feeds due to a damaged tube. No complications were encountered while pulling out the tubes after an average period of 5–6 weeks.