Clinical Burden of Laparoscopic Feeding Jejunostomy Tubes

Durability of surgically versus endoscopically placed jejunostomy tubes in non-oncology patients - A single centre experience over 10 years

BACKGROUND

Jejunal access is indicated in patients with impaired oral intake or gastroparesis who require enteral nutrition or medication delivery. There are various approaches to establishing jejunal access; including radiological, endoscopic and surgical methods. This study aims to evaluate the complication and re-intervention rates between endoscopic and surgical placement of jejunal tubes (JT).

METHOD

We retrospectively collected data on patients undergoing surgical or endoscopic placement of JT at a single centre over a ten-year period (2011-2021). We analysed the following information: age, gender, underlying pathology necessitating the JT placement, significant co-morbidities as well as the following outcome data: rates of tube occlusion, dislodgement and need for re-admission and re-intervention.

RESULTS

There were 165 patients included in the cohort. Of these, 96/165 underwent endoscopic placement either using Direct Percutaneous Endoscopic Jejunostomy (DPEJ) (14/96) or through Percutaneous Endoscopic Gastrostomy with Jejunal Extension (PEG-J) (82/96), and the remaining 69/165 underwent surgical placement either via a surgical flange (SF) tube (45/69) or the surgical Witzel (SW) technique (18/69). Idiopathic gastroparesis as an indication for JT placement (including Ehlers-Danlos Syndrome patients) affected 63.8 % of the surgical and 42.7 % of the endoscopic cohorts. At mean follow up of almost 17 months, the overall need for re-intervention, JT dislodgment and JT occlusion were 32.4 %, 8.8 % and 14.7 % in the surgical cohort, versus 62.8 %, 25.5 % and 27.7 % in the endoscopic cohort (p values of 0.0002, 0.0075 and 0.057, respectively). Individual re-intervention rates were 38.9 % for SW, 31.1 % for SF, 61 % for PEG-J and 64.3 % for DPEJ.

CONCLUSION

Surgical siting of JT demonstrates significantly reduced dislodgement rates, and requirement for re-intervention in the long-term as compared to endoscopic JT placement.

Surgical management of severe refractory gastroparesis: outcomes of jejunostomy tube placement

BACKGROUND

Surgical referrals for refractory gastroparesis (GP) are becoming more common as medical options are limited. Supplemental intestinal alimentation via feeding jejunostomy tubes (JT) is required to treat underlying malnutrition in only the most severe cases. The aim of this study was to determine predictive factors associated with successful restoration of oral nutrition after insertion of a JT for patients with severe malnutrition associated with GP.

METHODS

Retrospective review of all patients who had JT inserted between November 2007 and October 2023 at The Oregon Clinic for severe gastroparesis. Baseline demographics, comorbidities, objective studies, symptom scores and operative details were recorded. The primary outcome was successful return to independent oral intake defined as removal of the feeding tube without additional supplementation (TPN) at one year after the last procedure.

RESULTS

One hundred and eleven of 905 patients (12%) had JTs inserted during the study period. There was a total of 164 gastroparesis procedures including pyloric intervention (81), gastric neurostimulator (GNS) implantation (29), RNY gastrectomy (19), and fundoplication (35). Multiple procedures were performed in 48% during the disease course. Twenty-six (23.4%) patients achieved adequate return of oral intake and successful JT removal by 12 months, while (62%) required ongoing feeding access and/or TPN. Only pyloric intervention was independently associated with successful JT removal at one year (p = 0.011, OR 5.032, p = 0.045). Patients undergoing two procedures had the highest rate of JT removal within one year (36.6%, p = 0.036, OR 12.00, p = 0.022).

CONCLUSION

Malnutrition requiring feeding jejunostomy tubes is a rare complication of gastroparesis. When the disease has progressed to this stage, most patients remain j-tube dependent long-term despite surgical interventions. Pyloric intervention (laparoscopic pyloroplasty or endoscopic pyloromyotomy) substantially increases the likelihood of successful resumption of oral alimentation and subsequent liberation from feeding tubes. Pyloric intervention should be performed concurrently for any patient requiring a feeding jejunostomy for severe gastroparesis.

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BACKGROUND

Small bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management.

METHODS

Clinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation.

RESULTS

The nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775-0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686-0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model's area under the curve was 0.815 (95% confidence interval, 0.683-0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present.

CONCLUSION

The clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Laparoscopic Witzel jejunostomy

The placement of a feeding jejunostomy can be indicated in malnourished patients with gastric and oesophagogastric junction cancer to allow for enteral nutritional support. In these patients, the jejunostomy tube can be suitably placed at the time of staging laparoscopy. Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected, due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Here, we describe a novel technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach.

Jejunostomy Tube Insertion for Enteral Nutrition: Comparison of Outcomes after Laparoscopic versus Radiologic Insertion

PURPOSE

To retrospectively compare technical success and major complication rates of laparoscopically versus radiologically inserted jejunostomy tubes.

MATERIALS AND METHODS

In this single-institution retrospective study, 115 patients (60 men; mean age, 59.7 y) underwent attempted laparoscopic jejunostomy tube insertion as a standalone procedure during a 10-year period and 106 patients (64 men; mean age, 61.0 y) underwent attempted direct percutaneous radiologic jejunostomy tube insertion during an overlapping 6-year period. Clinical outcomes were retrospectively reviewed with primary focus on predictors of procedure-related major complications within 30 days.

RESULTS

Patients undergoing laparoscopic jejunostomy tube insertion were less likely to have previous major abdominal surgery (P < .001) or to be critically ill (P < .001) and had a higher body mass index (P = .001) than patients undergoing radiologic insertion. Technical success rates were 95% (110 of 115) for laparoscopic and 97% (103 of 106) for radiologic jejunostomy tube insertion (P = .72). Major procedural complications occurred in 7 patients (6%) in the laparoscopic group and in 5 (5%) in the radiologic group (P = 1.0). For laparoscopic jejunostomy tubes, only previous major abdominal surgery was significantly associated with a higher major procedure complication rate (14% [5 of 37] vs 3% [2 of 78] in those without; P = .039). In the radiologic jejunostomy group, only obesity was significantly associated with a higher major complication rate: 20% (2 of 10) vs 3% (3 of 96) in nonobese patients (P = .038).

CONCLUSIONS

Laparoscopic and radiologic jejunostomy tube insertion both showed high success and low complication rates. Previous major abdominal surgery and obesity may be pertinent discriminators for patient selection.

Endoscopically Guided Laparoscopic Gastrojejunostomy Tube Placement for Patients with Distal Esophageal Stents

Patients with distal esophageal pathology such as perforation, trachea-esophageal fistulae, and/ or obstructing gastroesophageal junction tumor present a challenging situation in terms of feeding access where an esophageal stent is placed across the gastroesophageal junction. In order to allow simultaneous gastric decompression and post-pyloric feeds without significant reflux up through the stent, a gastrojejunostomy (GJ) tube is a viable option. We hereby describe a hybrid approach to placing these GJ tubes in this cohort of patients using simultaneous laparoscopy, endoscopy, and fluoroscopy with minimal manipulation of the stent itself. We have employed this technique of placing GJ tubes 2-3 days following placement of the esophageal stent in six consecutive patients. All patients tolerated the procedure well without any complications. Endoscopically guided laparoscopic GJ tubes are ideal for bridging patients, with distal esophageal pathology requiring esophageal stents, to oral intake.