Laparoscopic Feeding Jejunostomy Research Articles

Outcome of laparoscopic feeding jejunostomy, comparison of a pure laparoscopic technique with Witzel’s tunnel to open technique: a retrospective cohort study

IntroductionObstructive upper GI cancer commonly uses feeding jejunostomy as a standard procedure. Surgeons implemented laparoscopic feeding jejunostomy via minimally invasive surgery, employing a variety of techniques. This study assessed the perioperative results, safety, and costs associated with laparoscopic versus open jejunostomy surgeries. We used only Witzel’s tunnel and standard laparoscopic instruments.Patients and methodsWe collected data from all patients who underwent feeding jejunostomy between January 2016 and June 2018. We recorded pertinent data on baseline, surgical outcomes, postoperative results, complications, and costs. The study excluded patients with jejunostomy as a conversion or an addition.ResultWe divided the 74 patients into 2 groups: 30 underwent laparoscopy and 44 underwent open surgery. The mean operational times were 89.67 and 91.64 min and showed no statistically significant difference (p = 0.678). The mean morphine dosage was significantly lower in the laparoscopic group (3.3 vs. 7.19, p = < 0.001). Laparoscopic surgery lowered the median time of feeding initiation, feeding accomplished, and postoperative stay, although none of these reached statistical significance. There were significantly higher surgical expenses in the laparoscopic group (16,410 vs. 11,685 Thai Baht) (p < 0.001); however, median overall expenditures did not significantly differ (105,147 vs. 116,198 Thai Baht) (p = 0.387). Laparoscopic versus open surgery had similar incidences of postoperative complications (20% vs. 25%, p = 0.846). The feeding tube catheter location was infection-free in all patients in our study.ConclusionLaparoscopic jejunostomy feeding was safe, and postoperative morphine consumption was lower. Increasing operational costs did not have a significant impact on overall expenditures. Witzel’s tunnel may reduce jejunostomy site infections.

Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!

Feeding jejunostomy (FJ) is a critical procedure to establish a source of enteral nutrition for upper gastrointestinal disorders. Minimally invasive surgery has the inherent benefit of better patient outcomes, less postoperative pain, and early discharge. This study aims to describe our total laparoscopic technique of Witzel FJ and to compare its outcome with its open counterpart. A retrospective database analysis was performed in patients who underwent laparoscopic (n = 20) and open (n = 21) FJ as a stand-alone procedure from July 2018 to July 2022. A readily available nasogastric tube (Ryles tube) and routine laparoscopic instruments were used to perform laparoscopic FJ. Perioperative data and postoperative outcomes were analyzed. Baseline preoperative variables were comparable in both groups. The median operative duration in the laparoscopic FJ group was 180 minutes vs. 60 minutes in the open FJ group (p = 0.01). Postoperative length of hospital stay was 3 days vs. 4 days in the laparoscopic and open FJ groups, respectively (p = 0.08). Four patients in the open FJ group suffered from an immediate postoperative complication (none in the laparoscopic FJ group). After a median follow-up of 10 months, fewer patients in the laparoscopic FJ group had complications such as tube clogging, tube dislodgement, surgical-site infection, and small bowel obstruction. Laparoscopic FJ with the Witzel technique is a safe and feasible procedure with a comparable outcome to the open technique. Patient selection is vital to overcome the initial learning curve.

Laparoscopic feeding jejunostomy using T-tube-technique and analysis of outcomes

Background: Enteral nutrition is of paramount importance in management of upper gastrointestinal tract malignancies. Although various access routes for enteral nutrition are available, feeding jejunostomy tube is preferred to other methods. Since minimally invasive techniques have many advantages, we decided to perform it during staging laparoscopy.Methods: The medical records of all patients who underwent laparoscopic feeding jejunostomy between October 2019 and September 2021, in the department of surgical gastroenterology, Madurai medical college were retrospectively reviewed. Patient demographics, ECOG performance status, types of malignancy, indications for feeding jejunostomy, operative time, time to start feeds, length of hospital stay and complications were analysed.Results: 75 patients underwent laparoscopic feeding jejunostomies (51 men and 24 women), with a mean age of 51.6±11.7 years, using this method. ECOG performance status was between 0-2. Mean operating time was 83±8.8 minutes. Mean length of hospital stay was 3.5 days. There was no conversion, however one patient required reoperation for peritubal leak.Conclusions: Feeding jejunostomy can be accomplished by a total laparoscopic technique using intracorporeal suturing. The technique we propose is relatively simple, reproducible, cost effective and can be widely adopted.

Laparoscopic vs. open feeding jejunostomy: a systemic review and meta-analysis.

Feeding jejunostomy is a solid way for patients to maintain enteral nutrition. However, debate over the superiority of the laparoscopic vs. laparotomic method has raised concerns in recent years. This systemic review and meta-analysis aimed to compare the postoperative outcomes between these two approaches. We searched PubMed, Embase, and Scopus from the date of inception to April 2022 for studies comparing laparoscopic and open feeding jejunostomy. Study characteristics and outcomes were extracted from the included articles. The primary outcome was the relative risk (RR) of postoperative complications in each group. We also analyzed the major/minor complication rates and operations, excluding major concomitant procedures. The risk of bias of included studies were assessed using the ROBINS-I tool. The certainty of evidence was rated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE). A total of seven retrospective studies with 1195 patients in total were included in this systemic review and meta-analysis. Laparoscopic feeding jejunostomy carried a significantly lower postoperative complication rate (RR: 0.62; 95% CI, 0.42-0.91, p = 0.02, low certainty of evidence) compared with laparotomy, and the heterogeneity was moderate (I2 = 34%, p = 0.18). After excluding major concomitant procedures, the RR between the laparoscopic and open group was 0.48 (95% CI, 0.33-0.70, p < 0.001, low certainty of evidence), suggesting that the laparoscopic approach was superior in terms of postoperative complications. Our results indicate that laparoscopic feeding jejunostomy might reduce the postoperative overall complication rate compared with open feeding jejunostomy.

Purely laparoscopic feeding jejunostomy: a procedure which deserves more attention

BackgroundLaparoscopic procedure has inherent merits of smaller incisions, better cosmesis, less postoperative pain, and earlier recovery. In the current study, we presented our method of purely laparoscopic feeding jejunostomy and compared its results with that of conventional open approach.MethodsWe retrospectively reviewed our patients from 2012 to 2019 who had received either laparoscopic jejunostomy (LJ, n = 29) or open ones (OJ, n = 94) in Chang Gung Memorial Hospital, Linkou. Peri-operative data and postoperative outcomes were analyzed.ResultsIn the current study, we employed 3-0 Vicryl, instead of V-loc barbed sutures, for laparoscopic jejunostomy. The mean operative duration of LJ group was about 30 min longer than the OJ group (159 ± 57.2 mins vs 128 ± 34.6 mins; P = 0.001). There were no intraoperative complications reported in both groups. The patients in the LJ group suffered significantly less postoperative pain than in the OJ group (mean NRS 2.03 ± 0.9 vs. 2.79 ± 1.2; P = 0.002). The majority of patients in both groups received early enteral nutrition (< 48 h) after the operation (86.2% vs. 74.5%; P = 0.143).ConclusionsOur study demonstrated that purely laparoscopic feeding jejunostomy is a safe and feasible procedure with less postoperative pain and excellent postoperative outcome. It also provides surgeons opportunities to enhance intracorporeal suture techniques.

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.

A simple, novel laparoscopic feeding jejunostomy technique to prevent bowel obstruction after esophagectomy: the “curtain method”

Feeding jejunostomy (FJ) is a common treatment to support patients with esophageal cancer after esophagectomy. However, severe FJ-related complications, such as bowel obstruction, occasionally occur. We investigated the ability of our simple, novel FJ technique, the "curtain method," to prevent bowel obstruction. In laparoscopic surgery, the main mechanism of bowel obstruction involves torsion of the mesentery accompanied by migration of the intestine across the fixed FJ through the space surrounded by a triangle comprising the ligament of Treitz, fixed FJ, and spleen rather than adhesion. Our "curtain method" involves closure of this triangle zone with omentum, and the appearance of the lifted omentum resembles a curtain. Sixty patients treated with this modified FJ were retrospectively compared with 13 patients treated with conventional FJ in terms of the incidence of bowel obstruction, peritonitis, stoma site infection, and catheter obstruction. From 2013 to 2017, 60 patients underwent esophagectomy and gastric conduit reconstruction accompanied by modified laparoscopic FJ. The median observation period, including the period after tube removal, was 644days. No FJ-associated bowel obstruction, the prevention of which was the primary aim, occurred in any patient. Likewise, no peritonitis or dislodgement occurred. Eight patients (13%) developed a stoma site infection with granulation. The feeding tube became occluded in 11 patients (18%); however, a new feeding tube was reinserted under fluoroscopy for all of these patients. From 2003 to 2012, 13 patients underwent conventional FJ. The median observation period was 387days. Three patients (23%) developed bowel obstruction by torsion 71 to 134days after the first surgery, and all were treated by emergency operations. Other FJ-related complications were not different from those in the modified FJ group. Our simple, novel technique, the "curtain method," for prevention of laparoscopic FJ-associated bowel obstruction after esophagectomy is a safe additional surgery.

Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome).

Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain. Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed. Ten patients (80% male) with a mean age of 61.3years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 ± 12h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8days (range 3-26), while inpatient LOS was 23.1 ± 12.5days (range 14-46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%. Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.

Laparoscopic Diamond Antroduodenostomy for Postcorrosive Pyloric Cicatrization: A Novel Approach.

Traditionally, Billroth I procedure or bypass gastrojejunostomy were the recommended approaches for management of postcorrosive complete gastric outlet obstruction (GOO), whereas Heineke Mickulicz pyloroplasty was recommended for moderate mucosal injury with partial cicatrization. In this study, laparoscopic diamond antroduodenostomy was carried out as an alternative minimally invasive approach for cases with pyloric cicatricial obstruction. Between January and December 2017, children who were referred to Pediatric Surgery Department, Cairo University Hospital, with GOO as a consequence of caustic liquid ingestions were included in this study. Laparoscopic diamond antroduodenostomy was performed for the presented cases. Through the year 2017, 5 cases were approached with laparoscopic diamond antroduodenostomy. Isolated pyloric cicatrization was evident in 4 cases, whereas synchronous insult to thoracic esophagus and pylorus was manifest in the fifth case. Laparoscopic feeding jejunostomy completed the procedure for the case with esophageal stricture. Contrast study-24 hour postoperatively-assured no radiological leaks in the presented cases, where enteral feeding was gradually commenced, and patients discharged home a day later. After a mean follow-up of 13.5 months, neither recurrence of obstructive symptoms nor dumping was displayed. Cosmetic outlook inherent to the minimally invasive approach was appreciated by the parents. Laparoscopic diamond antroduodenostomy is a feasible approach for management of postcorrosive pyloric obstruction. It allowed early enteral feeding, with no dumping symptoms, in addition to the fundamental advantages of minimally invasive surgery. A bigger series and longer follow-up is recommended to verify the reported results.

PS01.035: ILEOCOLONIC INTERPOSITION GRAFT: A SAFE AND FEASIBLE CONDUIT AFTER ESOPHAGOGASTRECTOMY

Abstract Background Restoration of gastrointestinal tract continuity with a suitable conduit is a vital step in esophagectomy. An adequate length of conduit, preservation of a good blood supply and functionality are keys to a successful outcome Methods We report two cases of successful ileocolonic interposition graft after esophagogastrectomy for caustic injury. Results Both patients were female with mean age of 45. They presented with progressive dysphagia and weight loss after alleged corrosive ingestion. Both had good functional status with no significant comorbidities. OGDS revealed long complex esophageal stricture and biopsy showed acute on chronic esophagitis. CT scan showed diffuse thickening of mid-distal esophagus and gastric stenosis. Both patients had refractory strictures with unsuccessful serial endoscopic dilatation. One patient had endoscopic nasoenteric tube insertion for enteral feeding while the other had laparoscopic feeding jejunostomy placed due to tight strictures. A 3-stage esophagogastrectomy with ileocolonic interposition graft was performed after optimization. Intra-operatively findings were dense fibrotic esophagus with diffuse gastric strictures. Ileocolonic graft comprising of the distal 15cm of terminal ileum, ascending colon and transverse colon was constructed based on middle colic arterial supply via marginal artery of Drummond. Vascularity and length of graft were confirmed before transection. Graft pull through was done via orthotopic posterior mediastinal route and isoperistaltic end-to-side esophago-ileocolonic anastomosis was performed at the neck. Contrast studies showed no anastomotic leak and both patients were discharged well on postoperative day 10. They had good oral intake with satisfactory weight gain with no functional disorders during follow up. Conclusion Ileocolonic interposition graft is a safe and feasible option if a gastric conduit is not available. In addition to the advantages of long length, reflux resistance and good blood supply, the smaller caliber of the ileum eases the pull through and the anastomosis due to a smaller size discrepancy. Disclosure All authors have declared no conflicts of interest.

PS01.108: SPONTANEOUS ESOPHAGOCUTANEOUS FISTULA IN KIKUCHI DISEASE

Abstract Background Kikuchi disease is a rare, self-limiting condition that is characterized by histiocytic necrotizing lymphadenitis with unknown pathogenesis. Common presentation is cervical lymphadenopathy and fever in a previously well young female. Mediastinal lymph node involvement is uncommon. Methods We report a case of spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymphadenopathy in a patient with Kikuchi disease. Results A 38-year-old lady presented with fever and right back pain of two weeks duration. She had background history of Kikuchi disease which was diagnosed 1 year ago. Examination revealed multiple enlarged left cervical lymph nodes and right back tenderness. CT scan showed an esophagocutaneous fistula with right paraspinal abscess and multiple enlarged cervical and mediastinal lymph nodes. OGDS revealed a 5mm fistula opening at right posterior wall of distal esophageal, 3cm proximal to esophagogastric junction. Rest of esophagus and stomach were normal. Tuberculosis and SLE workup were negative. Cervical lymph node biopsy was consistent with Kikuchi disease. She was treated as spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymph node with underlying Kikuchi disease. Percutaneous drainage of paraspinal abscess was done and antibiotics were commenced. Laparoscopic feeding jejunostomy was done for feeding. Esophageal stenting and endoscopic clipping of fistula were attempted but the fistula tract persisted. She then underwent laparoscopic excision of esophageal fistula tract (LEEFT). Intraoperative findings were dense inflamed paraesophageal tissue with thickened fistula tract at right posterolateral wall of distal esophagus with multiple enlarged mediastinal lymph nodes. Fistula tract and the lymph nodes were excised via laparoscopic transhiatal approach. She had an uneventful recovery and was discharged on post-operative day 7. Conclusion Spontaneous esophageal fistula is rare and necrotizing mediastinal lymphadenopathy needs to be considered. Laparoscopic excision of esophageal fistula tract (LEEFT) is a novel transhiatal approach and it is feasible in distally located fistula. Disclosure All authors have declared no conflicts of interest.

FA05.05: PROLONGED LAPAROSCOPIC GASTRIC ISCHEMIC CONDITIONING PRIOR TO ESOPHAGECTOMY IN PATIENTS OF ESOPHAGEAL CANCER: FEASIBILITY AND CLINICAL SIGNIFICANCE

Abstract Background The studies on gastric ischemic preconditioning in improving blood flow to the distal gastric conduit and reducing the incidence of anastomotic complications have yielded variable results. Lack of adequate time interval between gastric ischemic preconditioning and esophagectomy has been postulated as one of the reasons for lack of clinical benefit. Hence the present study was done to evaluate the feasibility and clinical outcome of prolonged gastric ischemic conditioning prior to esophagectomy. Methods Patients with locally advanced squamous cell carcinoma of the esophagus planned for neoadjuvant chemoradiotherapy followed by esophagectomy and gastric pull through were included in the prospective study. Prior to initiation of neoadjuvant therapy laparoscopic feeding jejunostomy with ischemic preconditioning by the ligation of left and the short gastric vessel was performed. All patients underwent thoracolaparoscopic esophagectomy with two field esophagectomy and cervical esophagogastric anastomosis using modified Orringer technique. Radiological assessment of the caliber of the right gastroepiploic artery (RGEA) and Immunohistologic analysis of Hypoxia-inducible factor – 1 alpha (HIF-1alpha) expression in the fundus to determine the degree of neovascularization was performed after ischemic preconditioning. The feasibility of laparoscopic gastric mobilization post ischemic preconditioning and cervical anastomotic leak rate was documented and compared with patients who did not undergo ischemic preconditioning. Results Fifteen patients underwent thoracolaparoscopic esophagectomy after a median time of 124 days post laparoscopic gastric ischemic preconditioning. Minor adhesions present in the gastrosplenic region did not interfere with laparoscopic gastric mobilization. The mean pre-ischemic conditioning diameter of RGEA increased from 2.18 mm to 2.25 mm post ischemic conditioning (P = 0.21). The median HIF-1 alpha index post ischemic conditioning was 0.6. The cervical anastomotic leak rate was less in patients who underwent ischemic preconditioning (1/14, 7.1%) compared to the patients who did not undergo ischemic preconditioning (6/16, 37.5%), although the difference was not statistically significant (P = 0.24) Conclusion Prolonged gastric ischemic preconditioning prior to esophagectomy is safe and does not interfere with laparoscopic gastric mobilization. It can potentially reduce cervical anastomotic complications post neoadjuvant chemoradiotherapy. Disclosure All authors have declared no conflicts of interest.

Blade-Directed Totally Laparoscopic Feeding Jejunostomy – How to do it

Blade-Directed Totally Laparoscopic Feeding Jejunostomy – How to do it

Laparoscopic surgical transmesocolic jejunostomy: A new surgical approach.

In cancer patients with tumors of the upper gastrointestinal tract, dysphagia and cachexia require gastrostomy or jejunostomy as the only options for enteral access for long-term feeding. In this article, the authors describe a modified placement of laparoscopic feeding jejunostomy applied during laparoscopic oncology layering technique. After performing an exploratory laparoscopy, a feeding jejunostomy is performed using a Foley silicon catheter, through an eyelet in the mesentery of the descending colon. After completing the introduction of the jejunal probe according to the Witzel technique, the intestinal segment of jejunum is attached to the internal sheath of the mesocolon using sutures polysorb 2/0, with the aim of removing the possible internal hernia and a jejunal torque that could cause an intestinal obstruction. There were no intraoperative complications or mortality. The technique described here provides most of the benefits of laparoscopic jejunostomy feeding, avoiding the possible internal hernia.

SUN-LB323: Completely Laparoscopic Feeding Jejunostomy – Own Surgical Technique Modification and Results of a Pilot Group

SUN-LB323: Completely Laparoscopic Feeding Jejunostomy – Own Surgical Technique Modification and Results of a Pilot Group

Laparoscopic Feeding Jejunostomy: A Simple Technique Using Kehr's T-Tube

Abstract Introduction: Enteral nutrition is preferred over parenteral route as it avoids septic complications associated with central venous catheter, is cost effective, and provides immunologic benefits. Percutaneous endoscopic gastrostomy is the preferred method of enteral access in most circumstances.1 However, jejunal feeds may be required for patients with gastroparesis and those at risk for aspiration. Standard techniques of laparoscopic feeding jejunostomy (FJ) require special instruments and expensive kits.2–12 A modified technique of laparoscopic FJ using an inexpensive T-tube and standard laparoscopic instruments is described. Methods: Four ports (two 10 mm and two 5 mm) are used for the procedure. A Kehr's 16F T-tube is modified by shortening the limbs. In addition, half, the diameter of the T-tube limb is excised. An enterotomy is made in the jejunum ~20 cm from the duodenojejunal flexure with a monopolar diathermy hook. The left anterior axillary port is removed and an artery forceps grasping...

Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes

BackgroundIn recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes.MethodsThe medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes.ResultsFifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days.ConclusionsLaparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success.

A Safe and Reliable Method of Laparoscopic Feeding Jejunostomy Tube Placement

This streaming video demonstrates our technique of laparoscopic placement of feeding jejunostomy tube. This technique can be employed before any upper gastrointestinal surgery. In our practice, we use this in patients diagnosed with gastroesophageal junction or esophageal cancer with obstructing symptoms and weight loss before instituting neoadjuvant therapy. This approach has manifold advantages. Same ports can be utilized subsequently for a minimally invasive esophagectomy, and the jejunostomy tube does not hinder the visualization throughout the procedure. Pre-therapy, this serves as a staging procedure combined with other modalities, provides enteral access, and optimizes nutritional status during the neoadjuvant treatment. From a technical standpoint, this mimics the steps of an open procedure and secures the jejunum to the abdominal wall under direct visualization. The prefashioned 16F T-tube minimizes the risk of clogging. The proximal and distal transfacial sutures avoid any torsion around the tube exit site. In conclusion, laparoscopic feeding jejunostomy, utilizing the technique demonstrated, is a safe and effective strategy that can be utilized before any upper gastrointestinal surgery, especially minimally invasive esophagectomy. Dr. Steven N. Hochwald is a consultant to Ethicon Endo-Surgery. Dr. Moshim Kukar has no conflicts of interest or financial ties to disclose. Runtime of video: 8 mins 15 secs

Pre-therapy Laparoscopic Feeding Jejunostomy is Safe and Effective in Patients Undergoing Minimally Invasive Esophagectomy for Cancer

ObjectiveLaparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DesignThis research is a retrospective case series. SettingThis study was conducted in a university tertiary care center. PatientsBetween August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. Main Outcome MeasuresThe outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. ResultsOne hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. ConclusionA laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

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.