Ann Thorac Surg 2006;82:756-758
© 2006 The Society of Thoracic Surgeons
How to do it
Jejunopexy for Selectively Placed Fluoroscopically Guided Percutaneous Jejunal Feeding Tubes
A.L. Jackson Slappy, MDa,b,*,
John A. Odell, MDa,b,
Ronald A. Hinder, MDc,
J. Mark McKinney, MDa,b,c
a Department of Surgery, Section of General Surgery, Florida
b Department of Surgery, Section of Cardiothoracic Surgery, Florida
c Department of Radiology, Mayo Clinic Jacksonville, Jacksonville, Florida
Accepted for publication July 6, 2005.
* Address correspondence to Dr Slappy, Mayo Clinic Jacksonville, Department of Surgery, Davis 3N, 4500 San Pablo Road, Jacksonville, FL 32224. (Email: slappya{at}bellsouth.net).
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Abstract
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Prophylactic placement of feeding jejunostomy tubes in patients undergoing esophagectomy or gastrectomy continues to be a common practice. The aim of jejunostomy is to maintain nutrition, especially with an anastomotic leak. Frequently total or supplemental nutrition through a jejunostomy is not required, rendering prophylactic placement unnecessary. In addition, feeding jejunostomy tubes have potentially serious complications.
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Introduction
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Management of patients without prophylactic placement of a jejunostomy tube is described. A site on the jejunum is marked with surgical clips, and an anterior abdominal wall jejunopexy is created. Fluoroscopically guided percutaneous placement is selectively utilized.
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Technique
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This procedure is indicated after total gastrectomy or esophagectomy in patients who may require postoperative tube feedings due to poor oral intake, altered mental status, prolonged ventilation, documented aspiration, sepsis, or complications of surgery, such as a leak or stricture. It is performed during the abdominal portion of the case prior to closure of the abdominal incision.
The ligament of Treitz is identified and a suitable loop of proximal jejunum is selected distal to this allowing pexy to the left anterior-lateral abdominal wall. On the antimesenteric border, two to four sutures surrounding an area of approximately 1.5 cm are placed and tacked to the left anterior-lateral abdominal wall. A ligaclip is placed on the serosa or sutures at this location to mark the proximal puncture site. In addition, one or two sutures are placed 5 to 8 cm distal to this and are similarly marked with a ligaclip to provide a suitable aiming point. The selected jejunal segment is kept in a straight line running cranial-caudal (Fig 1).
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Fig 1. Placement of anchoring sutures and marking with ligaclips on selected segment of jejunum. Note that two of four sutures at the proximal site were eliminated for clarity. Inset: Overview of site. Arrow indicates direction of view in figure.
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The patients remain on nasogastric tube suction and intravenous fluids for 5 days. A gastrograffin contrast study is performed to identify an anastomotic leak or stricture. If no problems arise, the nasogastric tube is removed and the patient's diet is advanced as tolerated. If oral intake is contraindicated, then fluoroscopically guided percutaneous placement of a jejunostomy feeding tube is performed.
Utilizing fluoroscopic guidance, percutaneous puncture of the surgically marked jejunum is made using the previously placed ligaclips as the proximal puncture site and distal aiming point. Contrast is instilled to verify an intraluminal location. A guidewire is inserted, the tract is dilated, and a 12-French feeding tube is advanced over the wire. The feeding tube is fixed to the skin with a suture, and a final injection of contrast is made to demonstrate proper intraluminal location and function of the jejunostomy tube (Fig 2). The tube may be used immediately.
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Fig 2. Placement of jejunostomy feeding tube over a wire using ligaclips as proximal and distal aiming points. Inset: Medial-lateral view of introducer and wire through abdominal wall into lumen of jejunal segment. Arrows indicate direction of insertion.
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We have used this technique 30 times and placed the jejunostomy tube on only two occasions for poor oral intake and an anastomotic leak. One complication of jejunal volvulus occurred when the jejunum was not broadly fixed to the abdominal wall.
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Comment
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Previously we placed jejunal feeding tubes in most esophagectomy and gastrectomy patients at the initial procedure. This practice allowed enteral alimentation when conditions such as anastomotic leak, inadequate or no oral intake, or prolonged mechanical ventilation occurred. Anastomotic leaks have been reported in 3% to 23% with a mortality of as much as 58% if intrathoracic [1]. Early enteral nutrition has been advocated to optimize wound healing, prevent bacterial translocation, and allow sufficient time for anastomotic healing and identification of leaks [2]. Although jejunal tube feeding can begin 6 to 8 hours after placement, many wait until it is demonstrated that early oral intake is insufficient or not possible [3].
Recently presented data supports changing this practice. Leak rates for intrathoracic anastomoses are being reported in the 3% to 4% range [1]. Orringer and colleagues reported a leak rate of 2.7% in cervical anastomoses after using a side-to-side stapled anastomosis. Anastomotic leaks typically occur around postoperative day 7 [2]. Patients as old as the age of 80 can tolerate as many as 6 days postoperatively without supplemental feedings [4]. In most patients, jejunostomy placement and feeding is uncomplicated. However, serious complications associated with jejunal feeding tubes have been reported, albeit they are relatively rare; these include bowel perforation or obstruction, pneumatosis intestinalis, intraabdominal jejunostomy leak, and skin site infections [3–5]. Therefore it is reasonable to consider avoiding prophylactic placement of jejunal feeding tubes at the time of initial surgery.
Some surgeons place jejunostomy feeding tubes routinely and allow for replacement after initial removal by a procedure similar to that described here [6]. Other techniques for postoperative, minimally invasive placement of percutaneous feeding tubes have been presented. These include computed tomographically guided fluoroscopic and laparoscopic methods [7, 8]. Potential complications and technical difficulties exacerbated by postoperative adhesions may make these methods less desirable. Laparoscopic techniques also require the use of general anesthesia and pneumoperitoneum.
It is our practice to create a jejunopexy during the abdominal portion of the surgery without feeding tube placement. Our interventional radiologists place a percutaneous jejunostomy feeding tube as dictated by the patient's clinical condition. Indications include anastomotic leak, stricture, difficulty swallowing, inadequate oral intake, or problems associated with cancer recurrence. By creating a broad-based jejunopexy and marking the proximal entry and distal aiming sites, several potential technical difficulties and complications associated with traditional fluoroscopically guided percutaneous jejunostomy are avoided. Specifically, the risk of blindly cannulating a poorly selected loop of small bowel is eliminated. Injury to adjacent structures or organs is also prevented, and the full length of the small bowel is available for adequate absorption. The potentially difficult maneuver of fixing the cannulation site to the abdominal wall is circumvented. Finally, using a broad based jejunopexy as opposed to a single anchored site decreases the risk of small bowel volvulus and obstruction.
We present a new method for the selective use of jejunostomy feeding in patients after esophagectomy or gastrectomy. This entails the construction of a broad-based jejunopexy to the left anterior-lateral abdominal wall marked with ligaclips, used to guide the percutaneous placement of a jejunostomy in selected patients requiring enteral feeding. This method avoids prophylactic feeding tube placement and its associated complications. It also avoids potential volvulus of the small bowel and minimizes complications that can occur when a jejunostomy tube is placed percutaneously after the initial procedure. A feeding tube can be safely placed by fluoroscopic guidance only when required.
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References
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- Huang GJ. Replacement of the esophagus with the stomachIn: Shields TW, LoCicero 3rd J, Ponn RB, editors. General Thoracic Surgery. 5th Ed. Philadelphia PA: Lippincott Williams & Wilkins; 2000. pp. 1730-1731.
- Orringer MB, Marshall B, Iannettoni, MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis J Thorac Cardiovasc Surg 2000;119:277-288.[Abstract/Free Full Text]
- Braga M, Gianotti L, Liotta S. Feeding the gut early after digestive surgeryresults of a nine-year experience. Clin Nutr 2002;21:59-65.[Medline]
- Fischer J. Metabolism in surgical patientsprotein, carbohydrate, and fat utilization by oral and parenteral routes. In: Townsend 2nd CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery. the biological basis of modern surgical practice. 16th Ed. Philadelphia: W. B. Saunders; 2001. pp. 101-104.
- Sarr MG. Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies Br J Surg 1999;86:557-561.[Medline]
- Brock MV, Venbrux AC, Heitmiller RF. Percutaneous replacement jejunostomy after esophagogastrectomy J Gastrointest Surg 2000;4:407-410.[Medline]
- Davies RP, Kew J, West GP. Percutaneous jejunostomy using CT fluoroscopy AJR 2001;176:808-810.[Free Full Text]
- Allen JW, Ali A, Wo J. Totally laparoscopic feeding jejunostomy Surg Endosc 2002;16:1802-1805.[Medline]
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Abstract
Introduction
