Jejunostomy Tube



Jejunostomy Tube


Rebecca L. Wiatrek

Lillian S. Kao





PATIENT HISTORY AND PHYSICAL FINDINGS



  • A complete surgical history should be elicited, focusing on prior abdominal operations.


  • A complete abdominal examination should be performed, noting prior incisions and hernias.


  • Because malnutrition may be an indication for placement of a jejunostomy tube, a complete nutritional history should be obtained including recent weight loss.


  • Physical examination should be focused on signs of severe malnutrition such as loss of subcutaneous fat, muscle wasting, and/or presence of edema and ascites.


  • The Subjective Global Assessment Score combines the history and physical examination to provide a rating from A (well nourished) to C (severely malnourished).


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • A nutritional assessment should be performed. Severe malnutrition may be a reason for placement of a jejunostomy tube, such as prior to major elective surgery. Indicators of preoperative malnutrition include weight loss greater than 10% to 15% over the previous 6 months, body mass index less than 18.5 kg/m2, Subjective Global Assessment Grade C, and/or serum albumin less than 3 g/dL.1


  • Electrolytes should be checked and replaced prior to surgery. An electrocardiogram should also be checked in order to rule out cardiac abnormalities and arrhythmias.


  • Additional studies and radiologic imaging should be based on the primary diagnosis. In patients with underlying malignancy, staging studies should be recent enough to ensure that there are no changes in the cancer status that may affect the operative plan.


SURGICAL MANAGEMENT


Preoperative Planning



  • Although enteral feeding is preferred to the parenteral route, the surgeon should ensure that there are no contraindications to enteral nutrition such as distal obstruction, ileus, highoutput enterocutaneous fistula, or shock. Alternatives to jejunostomy tubes include temporary nasally inserted feeding tubes and gastrostomy tubes. Temporary feeding access can be achieved using a nasogastric or a nasojejunal feeding tube; the latter can be placed with the assistance of fluoroscopy or endoscopy. Smaller diameter feeding tubes may be more comfortable for the patient but also may be more prone to clogging. Gastrostomy tubes for longer term feeding access can be placed endoscopically, radiologically, or surgically.


  • If enteral access is not the primary indication for surgery, then the complete operative plan should be considered. The anticipated duration of inability to take in oral nutrition or of inadequate nutrition (<60% of caloric requirement) should be taken in consideration when deciding whether or not to place a feeding jejunostomy tube as well as in deciding the route of placement (nasojejunal vs. surgical).1 In cancer patients, whether the goal of surgery is curative or palliative should be considered. A temporary feeding jejunostomy tube may be indicated after resection of cancer of the esophagus, stomach, or pancreas to allow continued distal enteral nutrition in the event of an anastomotic leak.


  • Palliative care may include placement of a surgical jejunostomy tube. Cancer patients who are not candidates for curative treatment should be assessed for their preferences, quality of life, and resources. The risks of surgical intervention should be weighed against the potential benefits of enteral nutrition. A candid discussion should be held with the patient regarding advanced directives and end-of-life care.


  • When enteral access is the primary indication for surgery, the surgeon should discuss the planned operative approach with the patient. When a laparoscopic jejunostomy tube is planned, the surgeon should discuss the possibility of conversion to open. If the jejunostomy tube is palliative, the surgeon should discuss the possibility of aborting the procedure when the risks outweigh the benefits (i.e., in the setting of carcinomatosis and inability to safely dissect the proximal jejunum).


  • Although no randomized trials exist regarding antibiotic prophylaxis prior to jejunostomy tube placement, there is high-quality evidence that antibiotic prophylaxis reduces surgical site infections across procedures and baseline risks.2 In addition, a meta-analysis of randomized controlled trials of antibiotic prophylaxis to prevent peristomal infection after percutaneous endoscopic gastrostomy demonstrated a significant risk reduction with cephalosporin and penicillinbased prophylaxis.3


Positioning



  • The patient should be positioned in the supine position. This is required for both laparoscopic and open techniques. For the laparoscopic approach, it is important to secure the patient to the bed with straps or tapes to allow for safe manipulation of the operating table.