Artificial nutrition refers to the provision or supplementation of daily metabolic nutrition requirements in patients with contraindications to feeding through the mouth or those with inadequate oral intake. Artificial nutrition is provided through parental or enteral access. Parenteral nutrition is provided through a large vein in the central venous system. Enteral nutrition makes use of the gastrointestinal (GI) tract to provide nutrition. Enteral access can be obtained by passing a feeding tube through the nose (nasogastric and nasojejunal), mouth (orogastric) at the bedside. It can also be achieved by surgical implantation of a feeding tube into the gut, such as a feeding gastrostomy (stomach) or a feeding jejunostomy (jejunum). Historically, enteral nutrition has not been as well emphasized as parenteral nutrition because of the belief that many disease states will prevent the gut from normal absorptive function. However, it is now clear that enteral nutrition is well tolerated even in severe disease states in critically ill patients. Moreover, enteral nutrition has been associated with reduced infectious complications, lower costs, and reduced length of hospital stay.
Feeding jejunostomy refers to a surgically inserted tube, preferably in the proximal jejunum, to provide enteral nutrition or administer medications. This is different from a definitive jejunostomy, which is commonly done as part of gastric resection by a Roux-en-Y technique. The first person to successfully place a feeding jejunostomy was Bush in 1858, performed on a patient with inoperable gastric cancer. Subsequently, Witzel, in 1891, developed the most commonly used technique for jejunostomy creation. A needle catheter technique was described by Delany et al. in 1973. The invention of the percutaneous endoscopic gastrostomy technique in the early 1980s paved the way for the development of the technique for feeding jejunostomy. After 1990, advances in laparoscopic surgical technique permitted the insertion of feeding jejunostomy techniques, Although techniques of jejunostomies have been modified over the years, the ‘Witzel technique’ is synonymous with feeding jejunostomy.
This chapter is aimed at presenting indications and contraindications of feeding jejunotomies. Furthermore, it describes the equipment, preparation, and techniques of positioning and potential complications with their management. The role of the interprofessional team strategies for improving care coordination and communication to advance feeding jejunostomies and improve outcomes is also addressed.
Feeding jejunostomy is a surgical route of enteral access. Indications for the placement of a feeding jejunostomy is when the oral route cannot be accessed for nutrition, when nasoenteral access is impossible when the time duration of artificial nutrition is more than six weeks and as an additional procedure after major gastrointestinal surgery with prolonged recovery time. Although the most common type of surgical enteral access is a gastrostomy, feeding jejunostomies are indicated when the GI tract is functioning, but there is an obstruction in the proximal part of the gut precluding placement of a gastrostomy tube.
One of the major group of candidates for jejunostomy feeding are patients with major gastrointestinal resection of the esophagus, stomach, pancreas, and duodenum. Myers et al. reviewed 2022 consecutive cases if needle catheter jejunostomies and reported that 89.7% (1939) was performed as an adjunct to laparotomies. Regardless of the pathology, many of these major surgical procedures are associated with prolonged recovery times, concern for the anastomosis including dysfunction or dehiscence, enteroenteral or enterocutaneous fistulas, and gastric atony. Jejunostomy feeding is also employed in patients as an adjunct to trauma laparotomies involving duodenal and pancreatic resection.
Jejunostomy feeding is indicated in patients with gastroparesis, which is characterized by decreased gastric motor function in the absence of mechanical obstruction. Strijbos et al. showed that 19 of 86 patients with gastroparesis ultimately required enteral nutrition through the placement of a PEG-Jejunostomy tube. The remaining responded to prokinetics and bowel rest. Jejunostomy feeding is also indicated in gastric outlet obstruction (GOO) caused by a mechanical cause such as an inoperable tumor, refractory peptic ulcer, or Bouveret syndrome. Jejunostomy feeding may, at times, be the last resort in inoperable duodenal tumors or strictures, and when the duodenum is compromised in conditions like pancreatitis. Palliative stenting may be considered for symptomatic improvement oral feeding in inoperative tumors.
A feeding jejunostomy tube may be used for the delivery of drugs like levodopa-carbidopa for the treatment of Parkinson disease. Continuous jejunal infusion of levodopa and carbidopa was associated with reduced motor fluctuations compared to oral delivery of the drug in patients with Parkinson disease.
The selection of a candidate for placement of a feeding jejunostomy involves multiple factors. The general condition of the patient, risk for aspiration, institutional facilities, and surgeons' experience must all be evaluated when determining the route for enteral nutrition.
Often, a feeding jejunostomy may be the only option for enteral access for a patient. It then becomes a potentially life-saving procedure, eliminating the need for parenteral nutrition and its associated risks. The only absolute contraindication to a feeding jejunostomy is bowel obstruction distal to the site of tube implantation. Relative contraindications can be classified as follows.
The equipment required depends on the techniques being used for the placement of the jejunostomy tube.
There are four techniques for jejunostomy placement: open surgical technique (longitudinal or transverse Witzel), laparoscopic technique, needle catheter technique, and percutaneous technique. Although the preferred technique depends on the type of patient and expertise of the surgeon, the minimally invasive techniques are standard of care.
Open Surgical Technique
The patient is prepped and draped with sterility. An exit site is chosen in the LUQ, preferable a few centimeters away from the midline. A stab incision is made and dissected with tonsil forceps. A loop of proximal jejunum is delivered into the wound. A diamond-shaped purse-string suture is tied to the antimesenteric border of the jejunal loop, and a small incision is given in the center of the suture, large enough to accommodate the jejunostomy tube. The tube is inserted into the jejunum with care to ensure enough length of tube into the jejunum to prevent the backflow of tube feeds. The purse-string suture is secured tightly without kinking the tube.
The Witzel technique is used to prevent extravasation of enteric contents at the exit site of the jejunostomy tube. This involves placing the tube along the length of the bowel for about 5 cm proximally and creating a serosal tunnel to imbricate the tube into position. The serosal tunnel is created by taking perpendicular Lambert sutures with 3-0 silk on either side of the tube. Once the tube is delivered through the abdominal wall, the jejunal loop is attached to the abdominal wall with seromuscular sutures. This is done to prevent bowel obstruction or volvulus.
It is a minimally invasive approach and preferred modality with the current advancement of technology. The patient is placed in a supine position initially, and after the creation of pneumoperitoneum and visual entry into the abdomen, the ligament of Treitz is visualized by upward retraction of the bowel and removal of omentum. The patient is kept in a reverse Trendelenburg position to allow the bowel to be traced. The jejunum is traced from the ligament of Treitz for 1-2 ft, and a site is chosen, which may be adhered to the abdominal wall. Four seromuscular sutures in the shape of a diamond are placed on the antimesenteric border of the jejunum. The loose ends of the sutures are used to pull the jejunum to the corresponding site over the abdominal wall. A percutaneous needle is used to enter the jejunum, and a guidewire is passed into the jejunum. The opposite side of the abdominal wall is inspected to make sure the guidewire has not passed through. Using serial dilators, the skin and subcutaneous tissue are dilated to make a track for the passage of the jejunostomy tube with a stent. Once the tube is in position, the stent is removed, and the balloon is inflated. The tube is secured in position, and laparoscopic incisions are closed with sutures and glue.
Needle Catheter Technique
This technique is often used as part of laparotomy with major gastrointestinal resection. A submucosal tunnel is created through the anti-mesenteric well of the jejunum with a needle catheter after its introduction into the abdominal cavity. The tunnel should be about 4-5 cm. This prevents the development of fistula after the placement of the tube. The catheter is introduced through the needle and sutured to the jejunal wall with a purse-string suture. Finally, the jejunum is attached to the peritoneal lining with sutures. Tube feeds can be started soon after surgery, within 6-12 hours.
Percutaneous Technique (Direct Percutaneous Endoscopic Jejunostomy)
Percutaneous insertion is done with the help of endoscopy. An enteroscope or colonoscope is passed into the jejunum. Transillumination of the tip of the scope is used to identify the position of the endoscope over the abdominal wall. A trocar is inserted through the abdominal wall into the jejunum, and a guidewire is passed distally into the jejunum. The tips of an awaiting snare or forceps are used to grasp the wire. A dilator is subsequently passed to create the track for the tube, and the tube is secured similarly to a ‘pull-PEG’ technique.
There is no evidence suggesting the type of jejunostomy tube with the lowest rate of complications; however, all techniques are associated with complications. Complications may be classified into mechanical, infectious, gastrointestinal, and metabolic complications.
Intestinal obstruction is a frequent complication and can be caused by over-inflation of the balloon; deflation of the balloon is both diagnostic and therapeutic. Transverse Witzel technique has been associated with the reflux of intestinal contents from intestinal ischemia and erosion of mucosa by the tube. Needle catheterization has been associated with withdrawal or blockage of the catheter, enterocutaneous fistulas, intestinal pneumatosis, and intestinal abscesses within the tunneled tube site. A laparoscopic jejunostomy is associated with inherent complications of laparoscopic surgery, such as problems arising from increased intra-abdominal pressure and anesthetics.
Pneumonia from aspiration and contamination of feeds are the two common infectious complications. Aspiration may result from improper placement of the jejunostomy tube. A tube placed proximally may be associated with reflux. Some studies have shown that continuous enteral nutrition is associated with aspiration pneumonia in critically ill patients.
Nausea, vomiting, diarrhea, abdominal distension, and colic are some of the frequently observed complications. The type of feed being used plays an essential role in the severity of complications.
Hypokalemia, hyperglycemia, and acid-base balance disturbances are frequently observed. Some causes are the improper placement of the jejunostomy tube, the use of incorrect feeds, and failure to correct resulting biochemical abnormalities. As the stomach and duodenum are bypassed, there is the possibility of deficiencies of vitamin B12 and iron, absorbed through these two organs, respectively. Initiation of tube feeding after a period of starvation may lead to the development of refeeding syndrome characterized by hypokalemia, hypophosphatemia, and hypomagnesemia. The pathophysiology is believed to be related to the release of insulin from the pancreas when feeding is initiated. It often manifests in ICU patients as hemodynamic instability, respiratory failure, and other non-specific features.
A feeding jejunostomy is a vital technique to achieve enteral access when a contraindication to the placement of a gastrostomy tube is present. It is sometimes also a part of a more extensive surgical procedure such as esophageal or gastric resection. Multiple techniques exist to place a feeding jejunostomy; however, minimally invasive methods are preferred. Complications are related to the type of feed used or mechanical causes. The feeding jejunostomy is a relatively simple procedure that can be performed by general surgeons.
When the decision is made to initiate enteral feeding in a patient, the involvement of a multidisciplinary team is vital in improving cost-effectiveness and patient satisfaction. The interprofessional team comprises of the provider, surgeon, dietician, speech-language therapist, and nurse. Home enteral nutrition team is a new concept that has been shown to increase the effectiveness of enteral feeding through reduction of hospital admissions, reduction of waste of feeds, and optimization of nutritional status. The surgeon is an integral part of the team in determining the best possible long-term enteral access for patients and managing complications.
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