Introduction

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 or nasojejunal) or the 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, enteral nutrition is well tolerated even in severely ill patients. Moreover, enteral nutrition has been associated with fewer infectious complications, lower costs, and shorter hospital stays.[1]

Feeding jejunostomy refers to a surgically inserted tube, preferably in the proximal jejunum, to provide enteral nutrition or administer medications. This differs from a definitive jejunostomy, commonly done as part of a gastric resection by a Roux-en-Y technique. Bush was the first person to successfully place a feeding jejunostomy in 1858, performed on a patient with inoperable gastric cancer.[2] 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.[3] The invention of percutaneous endoscopic gastrostomy in the early 1980s paved the way for the development of jejunostomy feeding. After 1990, advances in laparoscopic surgical techniques enabled the insertion of feeding jejunostomies. However, techniques for jejunostomies have evolved over the years; the ‘Witzel technique’ is synonymous with feeding jejunostomy.

This chapter aims to present indications and contraindications for feeding jejunostomies. Furthermore, it describes the equipment, preparation, positioning techniques, and potential complications in 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.

Indications

A jejunostomy feeding tube is a surgical route for enteral access. Indications for the placement of a feeding jejunostomy are when the oral route cannot be accessed for nutrition, when nasoenteral access is impossible, when the duration of artificial nutrition is more than six weeks, and as an additional procedure after major gastrointestinal surgery with a 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 groups of candidates for jejunostomy feeding is patients who have undergone major gastrointestinal resection of the esophagus, stomach, pancreas, or duodenum. Myers et al. reviewed 2022 consecutive cases of needle catheter jejunostomies and reported that 89.7% (1939) were performed as an adjunct to laparotomies.[4] Regardless of the pathology, many of these major surgical procedures are associated with prolonged recovery times and complications at 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.[5]

Jejunostomy feeding is indicated in patients with gastroparesis, characterized by decreased gastric motor function in the absence of mechanical obstruction. Strijbos et al reported that 19 of 86 patients with gastroparesis ultimately required enteral nutrition, as indicated by placement of a PEG-Jejunostomy tube. The remaining responded to prokinetics and bowel rest.[6] 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 sometimes 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 of oral feeding in inoperable tumors.[7] 

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.[8]

The selection of a candidate for placement of a feeding jejunostomy involves multiple factors. The patient's general condition, the risk for aspiration, institutional facilities, and surgeons' experience must all be evaluated when determining the route for enteral nutrition.

Contraindications

A feeding jejunostomy may often be the only option for enteral access for a patient. It 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.

Local 

• Abdominal wall infection at the placement site
• Severe ascites
• Peritonitis  
• History of bowel necrosis from the previous jejunostomy

Systemic 

• Severe coagulopathy (INR greater than 1.5, aPTT greater than 50 seconds, PLT less than 50,000/mm3)
• Hemodynamic instability requiring the use of vasopressors
• Ventilatory dependence preventing transport to the operating room [9]

Equipment

The required equipment depends on the techniques used to place the jejunostomy tube.

• Skin preparation with alcohol swabs/povidone-iodine swabs
• No. 11 surgical blade
• Lidocaine for local sedation
• Sterile gown and gloves
• 14-to18 gauge needle, a guidewire, a sheath, and a feeding jejunostomy tube
• Sutures for the creation of the Witzel tunnel
• Dressing with 2x2 or 4x4 gauze, adhesive tape
• Basic laparoscopic equipment in case of laparoscopic J-tube insertion

Preparation

The preparation of placing the jejunostomy tube includes:

• Informed consent regarding the procedure, type of anesthesia, and potential complications must be obtained. 
• The patient should be nil per os (NPO) for at least 6 hours before the procedure.
• Antibiotic pre-surgical prophylaxis should be administered according to institutional guidelines.
• Reliable bedside suction should be present.
• Intravenous sedation should be provided and administered at the bedside.

Technique or Treatment

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 patient type and surgeon expertise, minimally invasive techniques are the standard of care.

Open Surgical Technique

The patient is prepared and draped in a sterile fashion. An exit site is chosen in the LUQ, preferably 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 made 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 tube length 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 bowel for approximately 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.[10]

Laparoscopic Technique 

It is a minimally invasive approach and the preferred modality given current technological advancements. The patient is initially placed in the supine position. 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 the omentum. The patient is maintained in a reverse Trendelenburg position to facilitate tracing of the bowel. 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 ensure the guidewire has not passed through. Using serial dilatators, 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.[11][12]

Needle Catheter Technique

This technique is often used as part of a 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 a fistula after tube placement. 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 to 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.[13][14]

Complications

There is no evidence indicating which jejunostomy tube type has the lowest complication rate; however, all techniques are associated with complications. Complications may be classified as mechanical, infectious, gastrointestinal, or metabolic. 

Mechanical 

Intestinal obstruction is a common complication and can be caused by overinflation of the balloon; balloon deflation is both diagnostic and therapeutic. The transverse Witzel technique has been associated with intestinal content reflux from intestinal ischemia and with mucosal erosion caused by the tube. Needle catheterization has been associated with catheter withdrawal or blockage, enterocutaneous fistulas, intestinal pneumatosis, and intestinal abscesses at 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. 

Infectious 

Pneumonia from aspiration and feed contamination 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.[15]

Gastrointestinal 

Nausea, vomiting, diarrhea, abdominal distension, and colic are among the most frequently observed complications. The type of feed being used plays an essential role in the severity of complications.

Metabolic 

Hypokalemia, hyperglycemia, and acid-base balance disturbances are frequently observed. Some causes include improper placement of the jejunostomy tube, use of incorrect feeds, and failure to correct resulting biochemical abnormalities.[9] As the stomach and duodenum are bypassed, there is the possibility of vitamin B12 and iron deficiencies. 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 upon initiation of feeding. It often manifests in ICU patients as hemodynamic instability, respiratory failure, and other non-specific features.[16]

Clinical Significance

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.

Enhancing Healthcare Team Outcomes

When the decision is made to initiate enteral feeding in a patient, the involvement of an interprofessional team is vital in improving cost-effectiveness and patient satisfaction.[17][18] The interprofessional team comprises the provider, surgeon, dietitian, speech-language therapist, and nurse. The home enteral nutrition team is a new concept that has been shown to improve the effectiveness of enteral feeding by reducing hospital admissions, reducing feed waste, and optimizing nutritional status.[17] The surgeon is integral to the team in determining the optimal long-term enteral access for patients and in managing complications.

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

Seres DS, Valcarcel M, Guillaume A. Advantages of enteral nutrition over parenteral nutrition. Ther Adv Gastroenterol. 2013 Mar;6(2):157-67. [PMC free article: PMC3589130] [PubMed: 23503324]

2.

Gerndt SJ, Orringer MB. Tube jejunostomy as an adjunct to esophagectomy. Surgery. 1994 Feb;115(2):164-9. [PubMed: 8310404]

3.

Delany HM, Carnevale NJ, Garvey JW. Jejunostomy by a needle catheter technique. Surgery. 1973 May;73(5):786-90. [PubMed: 4697097]

4.

Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg. 1995 Dec;170(6):547-50; discussion 550-1. [PubMed: 7491998]

5.

Holmes JH, Brundage SI, Yuen P, Hall RA, Maier RV, Jurkovich GJ. Complications of surgical feeding jejunostomy in trauma patients. J Trauma. 1999 Dec;47(6):1009-12. [PubMed: 10608526]

6.

Strijbos D, Keszthelyi D, Smeets FGM, Kruimel J, Gilissen LPL, de Ridder R, Conchillo JM, Masclee AAM. Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis. Neurogastroenterol Motil. 2019 Jun;31(6):e13588. [PMC free article: PMC6850664] [PubMed: 30947400]

7.

Nunes G, Fonseca J, Barata AT, Dinis-Ribeiro M, Pimentel-Nunes P. Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique? GE Port J Gastroenterol. 2020 Apr;27(3):172-184. [PMC free article: PMC7250336] [PubMed: 32509923]

8.

Zulli C, Sica M, De Micco R, Del Prete A, Amato MR, Tessitore A, Ferraro F, Esposito P. Continuous intra jejunal infusion of levodopa-carbidopa intestinal gel by jejunal extension tube placement through percutaneous endoscopic gastrostomy for patients with advanced Parkinson's disease: a preliminary study. Eur Rev Med Pharmacol Sci. 2016 Jun;20(11):2413-7. [PubMed: 27338069]

9.

Tapia J, Murguia R, Garcia G, de los Monteros PE, Oñate E. Jejunostomy: techniques, indications, and complications. World J Surg. 1999 Jun;23(6):596-602. [PubMed: 10227930]

10.

Schwaitzberg SD, Sable DB. Transverse Witzel-T-tube feeding jejunostomy. JPEN J Parenter Enteral Nutr. 1995 Jul-Aug;19(4):326-7. [PubMed: 8523634]

11.

Hsieh JS, Wu CF, Chen FM, Wang JY, Huang TJ. Laparoscopic Witzel gastrostomy--a reappraised technique. Surg Endosc. 2007 May;21(5):793-7. [PubMed: 17180291]

12.

Han-Geurts IJ, Lim A, Stijnen T, Bonjer HJ. Laparoscopic feeding jejunostomy: a systematic review. Surg Endosc. 2005 Jul;19(7):951-7. [PubMed: 15920697]

13.

Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014 Jul 14;20(26):8505-24. [PMC free article: PMC4093701] [PubMed: 25024606]

14.

Mellert J, Naruhn MB, Grund KE, Becker HD. Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results. Surg Endosc. 1994 Aug;8(8):867-9; discussion 869-70. [PubMed: 7992151]

15.

Jacobs S, Chang RW, Lee B, Bartlett FW. Continuous enteral feeding: a major cause of pneumonia among ventilated intensive care unit patients. JPEN J Parenter Enteral Nutr. 1990 Jul-Aug;14(4):353-6. [PubMed: 2119441]

16.

Khan LU, Ahmed J, Khan S, Macfie J. Refeeding syndrome: a literature review. Gastroenterol Res Pract. 2011;2011 [PMC free article: PMC2945646] [PubMed: 20886063]

17.

Dinenage S, Gower M, Van Wyk J, Blamey A, Ashbolt K, Sutcliffe M, Green SM. Development and evaluation of a home enteral nutrition team. Nutrients. 2015 Mar 05;7(3):1607-17. [PMC free article: PMC4377869] [PubMed: 25751819]

18.

Ojo O. The challenges of home enteral tube feeding: a global perspective. Nutrients. 2015 Apr 08;7(4):2524-38. [PMC free article: PMC4425159] [PubMed: 25856223]

Disclosure: Jason D'Cruz declares no relevant financial relationships with ineligible companies.

Disclosure: Marco Cascella declares no relevant financial relationships with ineligible companies.