Complications of Jejunostomy Feeding Tubes: A Single Center Experience of 546 Cases

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.

Continuous versus intermittent tube feeding after feeding jejunostomy, a pilot randomized controlled trial

BACKGROUND

Feeding jejunostomy is employed in cases of upper gastrointestinal tract disorders; nonetheless, there are limited guidelines about post-procedural feeding approaches. This study aims to examine the effects of continuous and intermittent feeding strategies on time to achieve full feeding, gastrointestinal adverse events, and metabolic alterations following jejunostomy surgery.

METHOD

This randomized controlled pilot non-inferiority trial included 40 people with diseases of the upper GI tract who had a feeding jejunostomy at Chiang Mai University Hospital. The patients were not blinded and were randomly split into two groups using the block-of-four method. After completion of recruitment, 18 patients in the continuous feeding group and 20 patients in the intermittent feeding group (5 separated meals in 15 min each) were included in the final analysis. The primary outcome was determined based on the time to achieve complete feeding (30 ml/kg/day). The secondary outcome includes the presence of adverse gastrointestinal symptoms and any metabolic alterations.

RESULTS

There were no statistically significant differences in the time taken to achieve a full feed in continuous and intermittent (48 ± 0 h. vs. 50.4 ± 5.6 h, p = 0.080) or as regards gastrointestinal adverse events, abdominal discomfort (27.8 vs. 30.0 %) and diarrhea (5.6 vs. 10 %) (p = 1.000). The metabolic outcome also showed no difference between the two groups.

CONCLUSION

There was no significant difference between continuous and intermittent feeding in terms of the time required to achieve a full feed, gastrointestinal adverse events such as abdominal discomfort and diarrhea, or metabolic changes.

TRIAL REGISTRATION

TCTR20241008004; Thai Clinical Trials Registry.

Optimization of Exocrine Pancreatic Insufficiency in Pancreatic Adenocarcinoma Patients

BACKGROUND/OBJECTIVES

This study explores the optimization of exocrine pancreatic insufficiency (EPI) management in pancreatic adenocarcinoma patients, focusing on the scientific advancements and technological interventions available to improve patient outcomes, including oral pancreatic enzyme replacement therapy (PERT) and immobilized lipase cartridge (RELiZORB®). This was a prospective Institutional Review Board (IRB)-approved study from October 2019 through to August 2021 at the Louisville Medical Center in collaboration with Norton Healthcare and the University of Louisville Division of Surgical Oncology. Patients with a diagnosis of pancreatic adenocarcinoma (Stage 2 or 3) who underwent oncologic surgical resection were included in this study.

METHODS

Patients were contacted at pre-defined intervals (prior to surgery, before hospital discharge, and 2, 4, 6, and 12 weeks after surgery) to complete nutrition evaluation, EPI assessment, and quality of life questionnaires to identify the severity and frequency of gastrointestinal (GI) symptoms.

RESULTS

EPI symptoms were reported in 28 of the 35 total patients studied (80%). Jejunostomy tubes were placed during oncologic surgery in 25 of the 35 total patients studied (71%), and 12 of the 25 patients with a jejunostomy tube utilized enzyme cartridges to manage EPI symptoms while on supplemental tube feeding (48%). EPI symptoms were reported in 8 of the 10 patients without a feeding tube (80%), and their EPI symptoms were managed with PERT alone. EPI interventions, both oral PERT and immobilized cartridges, were associated with a decrease in EPI symptoms after surgery and improved quality of life (QOL).

CONCLUSIONS

Overall, early optimization of EPI is crucial to enhance overall patient care, return to oncology therapy after surgery, and improve quality of life in pancreatic adenocarcinoma patients.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.

MATERIALS AND METHODS

This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.

RESULTS

In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).

CONCLUSION

Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Nutritional approaches for gastroparesis

Patients with gastroparesis often have signs and symptoms including nausea, vomiting, epigastric discomfort, and early satiety, thus leading to inadequate food intake and a high risk of malnutrition. There is a considerable scarcity of data about nutritional strategies for gastroparesis, and current practices rely on extrapolated evidence. Some approaches include the modification of food composition, food consistency, and food volume in the context of delayed gastric emptying. If the patient is unable to consume adequate calories through a solid food diet, stepwise nutritional interventions could include the use of liquid meals, oral nutrition supplements, enteral nutrition, and parenteral nutrition. This Review discusses the role, rationale, and current evidence of diverse nutritional interventions in the management of gastroparesis.