Open Jejunostomy Tube Placement

Chapter 14 Open Jejunostomy Tube Placement



Eleanor Faherty, MD, Rebecca Evangelista, MD



INTRODUCTION


Enteral nutrition is the preferred method of feeding patients who are unable to meet their caloric needs through the conventional oral route. Feeds are most commonly initiated via the stomach, but the jejunum is an acceptable alternative. Jejunal feeding tubes are often placed in patients who are at increased risk of aspiration of gastric contents. It is also an option when the stomach is not suitable for a gastrostomy tube because of previous surgery, distal obstruction, or disease. Jejunostomy tubes are also often placed during extensive enteric reconstructions in which delayed oral intake is anticipated. Such tubes provide distal access for enteral nutrition and help to avoid the need for parenteral nutrition and prolonged vascular access.1



INDICATIONS



• High risk for aspiration

• Gastric outlet obstruction

• Gastric dysmotility (i.e., gastroparesis)

• Previous gastric resection or gastric bypass

• Status after esophagogastrectomy

• Inability to place percutaneous endoscopic gastrostomy (PEG) tube

• Enteral access needed after extensive surgical procedure

• Long-term enteral access for chemotherapy patients2,3


OPERATIVE STEPS2



Step 1 Upper midline incision

Step 2 Identification of the jejunum approximately 20 cm distal to ligament of Treitz

Step 3 Placement of pursestring suture in antimesenteric side of jejunum

Step 4 Jejunostomy

Step 5 Placement of jejunostomy tube into jejunum through abdominal wall*

Step 6 Suturing of jejunal wall to anterior abdominal wall around tube insertion site

Step 7 Close midline incision

Step 8 External suturing of tube to anterior abdominal wall


OPERATIVE PROCEDURE



Upper Midline Incision



Intra-Abdominal Injuries with Midline Incision


To obtain access and adequate exposure of the jejunum for an open jejunostomy tube placement, an upper midline incision is the standard choice. Care should be taken if the patient has had prior laparotomies and, thus, has resultant scar tissue. Complications related to laparotomy incisions are discussed in Section I, Chapter 7, Laparoscopic Surgery.



Identification of the Jejunum



Incorrect Identification of the Ligament of Treitz


If the ligament of Treitz is not identified or is incorrectly identified, the placement of the jejunostomy tube may not be in the correct location in the jejunum. Ideal placement is considered to be approximately 20 to 30 cm distal to the ligament of Treitz.



• Consequence



Malabsorption may result if the tube is placed too distally. If the tube is too proximal, it is possible that enteral feeds could reflux via the duodenum into the stomach and possibly cause aspiration.

Grade 2/3 complication


• Repair



If incorrect placement of the tube is noticed intraoperatively, the tube may be removed and the jejunostomy closed primarily. If proximal or distal placement is suspected from clinical factors, a contrast study may be performed to confirm tube location. If the study confirms either proximal or distal placement and the patient is not tolerating enteral feeding, a new tube should be placed.


• Prevention



Correct identification of the ligament of Treitz will aid in proper tube placement. Locating the ligament is most easily accomplished by reflecting the transverse colon and omentum superiorly and following the transverse colon mesentery to its posterior origin. The ligament of Trietz should be visualized and palpated just to the left of midline in its posterior location.


Placement of the Pursestring Suture in the Antimesentric Jejunum



Inadequate Suture Thickness



• Consequence



Tear of the jejunal wall with pull through of the suture. This can result in an immediate or delayed full-thickness tear in the jejunal wall, allowing for potential leak.

Related posts:

  1. Supraclavicular Lymph Node Biopsy
  2. Lateral Pancreaticojejunostomy (Puestow) Procedure
  3. Left Colectomy: Open and Laparoscopic
  4. Bronchial and Vascular Sleeve Lobectomy

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Open Jejunostomy Tube Placement

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