Jejunostomy Tube Placement in Gastrointestinal Surgery: What Surgeons Need to Know

Jejunostomy tube placement is a surgical procedure commonly performed in patients who require long-term enteral nutrition but cannot receive it orally or through a nasogastric tube. This procedure is particularly important in patients with impaired gastric motility, severe reflux, or after certain surgeries where the upper gastrointestinal tract is not functional. As a surgeon, understanding the intricacies of jejunostomy tube placement, including indications, techniques, postoperative care, and potential complications, is crucial for successful patient outcomes.

Indications for Jejunostomy Tube Placement

Jejunostomy tube placement is indicated in various clinical scenarios where direct feeding into the jejunum is necessary. These include:

1. Gastrointestinal Surgery: Patients undergoing surgeries such as esophagectomy, gastrectomy, or pancreaticoduodenectomy often require a jejunostomy tube for postoperative nutritional support.
2. Gastric Motility Disorders: Conditions like gastroparesis, where the stomach’s ability to empty its contents is impaired, may necessitate jejunostomy tube placement.
3. Severe Gastroesophageal Reflux Disease (GERD): In cases where reflux is severe and unresponsive to medical treatment, and where there is a risk of aspiration, feeding directly into the jejunum may be safer.
4. Neurological Disorders: Patients with neurological conditions that impair swallowing, such as stroke, amyotrophic lateral sclerosis (ALS), or severe traumatic brain injury, may require a jejunostomy tube.
5. Cancer: Patients with head and neck cancers, esophageal cancer, or advanced gastric cancer may benefit from jejunostomy tube placement when oral intake is not feasible.
6. Critical Illness: In critically ill patients who require prolonged mechanical ventilation, a jejunostomy tube may be necessary to ensure adequate nutritional support.

Preoperative Evaluation

Before proceeding with jejunostomy tube placement, a thorough preoperative evaluation is essential. This evaluation should include:

1. Nutritional Assessment: Evaluate the patient’s nutritional status to determine the urgency and type of nutritional support required. Laboratory tests, including serum albumin and prealbumin levels, can provide insight into the patient’s nutritional needs.
2. Imaging Studies: Depending on the underlying condition, imaging studies such as abdominal CT or MRI may be necessary to assess the anatomy and plan the surgical approach.
3. Gastrointestinal Function Tests: Tests such as gastric emptying studies may be performed in patients with suspected gastric motility disorders.
4. Patient Counseling: Discuss the procedure, its risks, benefits, and alternatives with the patient and their family. Ensure informed consent is obtained, and address any concerns they may have.
5. Risk Stratification: Assess the patient’s overall health and comorbidities to stratify the risk of surgery. This includes evaluating cardiovascular status, pulmonary function, and any history of previous abdominal surgeries that may complicate the procedure.

Contraindications

Jejunostomy tube placement, while generally safe, may be contraindicated in certain situations:

1. Severe Coagulopathy: Patients with uncontrolled coagulopathy are at increased risk of bleeding complications during and after the procedure.
2. Diffuse Peritonitis: Active infection in the abdominal cavity is a contraindication due to the risk of spreading the infection.
3. Extensive Abdominal Adhesions: Previous abdominal surgeries may lead to extensive adhesions, making the procedure technically challenging and increasing the risk of complications.
4. Unstable Medical Condition: Patients who are hemodynamically unstable or have severe respiratory compromise may not tolerate the procedure well.
5. Short Bowel Syndrome: In patients with severe short bowel syndrome, the jejunum may not be able to adequately absorb nutrients, making the procedure less effective.

Surgical Techniques and Steps

Several techniques are available for jejunostomy tube placement, including open surgery, laparoscopic, and endoscopic approaches. The choice of technique depends on the patient’s condition, surgeon’s expertise, and available resources.

1. Open Jejunostomy:
   • Incision and Exposure: A midline or left upper quadrant incision is made to access the jejunum. The bowel is identified and gently exteriorized.
   • Creation of a Stoma: A loop of the jejunum is selected, and a small enterotomy is created. The tube is then inserted through the enterotomy and secured with purse-string sutures.
   • Fixation: The jejunal loop is anchored to the abdominal wall to prevent migration of the tube. The tube is brought out through a separate stab incision in the abdominal wall.
   • Closure: The abdominal wall is closed in layers, taking care to avoid tension on the tube.
2. Laparoscopic Jejunostomy:
   • Port Placement: Laparoscopic ports are placed, usually in a triangular configuration, to allow access to the jejunum.
   • Identification of the Jejunum: The jejunum is identified laparoscopically, and a suitable loop is selected for the jejunostomy.
   • Tube Insertion: A needle catheter jejunostomy (NCJ) or other tube types can be inserted under direct visualization, and the tube is secured with sutures.
   • Closure: The port sites are closed, and the tube is brought out through one of the port incisions or a separate site.
3. Endoscopic Jejunostomy:
   • Endoscopic Access: An endoscope is passed into the jejunum, and a guidewire is advanced through the abdominal wall.
   • Tube Placement: The tube is then introduced over the guidewire and secured with internal and external bolsters.
   • Verification: The position of the tube is verified endoscopically, and any adjustments are made as necessary.

Postoperative Care

Postoperative care is critical to the success of jejunostomy tube placement and the prevention of complications. Key aspects include:

1. Tube Care: Ensure that the tube is properly secured and inspect the site regularly for signs of infection or dislodgement. The stoma should be kept clean and dry.
2. Nutritional Support: Begin enteral feeding gradually, starting with a low-volume, isotonic formula. Monitor the patient’s tolerance to feeding, including signs of nausea, vomiting, or diarrhea.
3. Pain Management: Administer appropriate analgesics to manage postoperative pain, but avoid narcotics that may slow gastrointestinal motility.
4. Monitoring for Complications: Regularly assess the patient for potential complications such as infection, bleeding, or tube dislodgement. Abdominal imaging may be required if there are concerns about tube positioning.
5. Education: Educate the patient and their caregivers on how to care for the tube at home, including how to flush the tube, recognize signs of infection, and manage minor complications.

Possible Complications

While jejunostomy tube placement is generally safe, several complications can occur, including:

1. Infection: Stoma infections are common and can usually be managed with local care and antibiotics.
2. Tube Dislodgement: Accidental dislodgement of the tube can occur, especially in the early postoperative period. If dislodgement occurs, prompt re-insertion is necessary to prevent the stoma from closing.
3. Peritonitis: Although rare, peritonitis can occur if there is leakage of enteral feed into the peritoneal cavity. This requires immediate surgical intervention.
4. Bowel Obstruction: The tube or its associated sutures can cause mechanical obstruction of the bowel. This may require surgical revision.
5. Bleeding: Bleeding can occur at the insertion site or internally. This may require intervention depending on the severity.

Different Techniques

There are various techniques for jejunostomy tube placement, each with its advantages and limitations:

1. Needle Catheter Jejunostomy (NCJ): This is a less invasive option, often performed laparoscopically, where a fine-bore tube is inserted into the jejunum using a needle. It is ideal for patients who require short-term feeding but can be prone to blockage.
2. Witzel Jejunostomy: This involves creating a subserosal tunnel around the tube to reduce the risk of leakage and peritonitis. It is more secure but technically more complex.
3. Roux-en-Y Jejunostomy: In some cases, a Roux-en-Y loop of jejunum is brought to the abdominal wall, particularly in patients with complex gastrointestinal anatomy.
4. Percutaneous Endoscopic Jejunostomy (PEJ): This is a minimally invasive technique where the tube is placed endoscopically, reducing recovery time. However, it may not be suitable for all patients, particularly those with altered anatomy or previous surgeries.

Prognosis and Outcome

The prognosis for patients undergoing jejunostomy tube placement is generally favorable, especially when the procedure is performed for appropriate indications. The tube allows for adequate nutritional support, which is crucial for recovery in patients with compromised oral intake. Long-term outcomes depend on the underlying condition being treated, but many patients experience significant improvements in their nutritional status and overall quality of life.

Alternative Options

While jejunostomy tube placement is effective, alternative options may be considered in certain cases:

1. Gastrostomy Tube Placement: For patients who do not require direct jejunal feeding, a gastrostomy tube may be a simpler and equally effective option.
2. Nasogastric or Nasointestinal Feeding: In patients expected to resume oral intake shortly, temporary feeding through a nasogastric or nasointestinal tube may be preferred.
3. Parenteral Nutrition: In patients where enteral feeding is not possible or contraindicated, total parenteral nutrition (TPN) can be used, although it carries risks of infection and liver dysfunction.

Average Cost

The cost of jejunostomy tube placement can vary widely depending on the healthcare system, the complexity of the procedure, and the type of tube used. On average, the procedure may cost between $5,000 to $15,000, including hospital stay, surgical fees, and postoperative care. Laparoscopic and endoscopic techniques may be more expensive due to the need for specialized equipment.

Recent Advances

Recent advances in jejunostomy tube placement focus on improving safety and reducing complications. These include:

1. Biodegradable Tubes: Research is ongoing into the development of biodegradable feeding tubes that would eliminate the need for removal and reduce long-term complications.
2. Enhanced Imaging Techniques: The use of advanced imaging modalities, such as intraoperative ultrasound and fluorescence imaging, has improved the precision of tube placement, reducing the risk of complications.
3. Endoscopic Innovations: Advances in endoscopic technology have made percutaneous endoscopic jejunostomy (PEJ) safer and more accessible, with improved outcomes.