Open Jejunostomy

Steven J. Hughes, MD and A. James Moser, MD

he use ofjejunostomy tubes for enteral nutrition is a feeding jejunostomy tubes 3 and may be inserted percuta-
T common clinical practice. Although the surgical pro- neously at significant cost savings. 4 Because bolus feed-
cedure for placing jejunostomy tubes is thought to be ings through a gastrostomy do not require a delivery
straightforward, it is associated with a number of compli- pump, daily maintenance of gastrostomy tubes is less
cations, some of which are potentially life-threatening. expensive than continuous feeding through a jejunos-
These include peritoneal soilage from postoperative dis- tomy.
lodgement of the tube, bowel obstruction from volvulus
at the site of tube insertion, and necrotizing fasciitis of the Standard Jejunostomy Tube versus Combined
abdominal wall as a result of leakage at the site of tube Gastrojejunostomy Tube
insertion into the bowel or from sutures tied too tightly Our preferred method for providing enteral nutrition di-
around the tube. These complications occur with suffi- rectly into the small bowel utilizes a combined gastroje-
cient frequency to offset the benefits of early postopera- junostomy tube that enters the stomach and passes into
tive feeding in patients undergoing elective surgery for the proximal jejunum through the pylorus. 5'6 The place-
gastrointestinal malignancies. ~ Overall tube-related mor- ment of gastrojejunostomy tubes is associated with fewer
bidity in several series averages 9% and may be associated postoperative complications than standard jejunostomy
with unanticipated mortality. 1,2 Thus, careful patient se- tubes and a lower incidence of both enteric leakage and
lection and attention to surgical technique are essential additional surgery for tube repair. 2 Combined gastrojeju-
when performing this procedure. nostomy tubes allow continuous gastric decompression,
eliminate the risk of torsion or small bowel obstruction
created at the site ofjejunostomy tube insertion, and clog
Patient Selection
less frequently because of their large caliber. Moreover,
Surgical jejunostomy should be considered whenever a these tubes may be used for bolus feeding into the stom-
patient requires long-term enteral access but is not a can- ach once gastric ileus or obstruction has resolved.
didate for gastric feeding. Standard indications for a feed- One potential disadvantage of the combined tube is
ing jejunostomy include esophagectomy, distal or total that it probably does not provide as effective gastric de-
gastrectomy, and surgery to treat duodenal or esophageal compression as that provided by a separate decompres-
perforation when separate tubes for gastric decompres- sive gastrostomy tube. The drainage ports of the gastroje-
sion and enteral feeding are required. Other indications junostomy tube reside anteriorly within the stomach and
include severe gastroparesis not amenable to medical man- do not empty the fundus of the stomach well in a supine
agement, significant gastroesophageal reflux, and short- patient. Recent modifications in the design of these tubes
bowel syndrome requiring continuous enteral feeding. In have virtually eliminated their tendency to migrate back
general, gastrostomy tubes have fewer complications than into the stomach.

From the University of Pittsburgh School of Medicine and the VA Pittsburgh

Medical Center, Pittsburgh, PA.
Address reprint requests to A. James Moser, MD, Assistant Professor of Surgery,
Cell Biology, and Physiology, University of Pittsburgh School of Medicine, Suite
300, Lillian S. Kaufmann Bldg., 3471 Fifth Avenue, Pittsburgh PA 15213. E-mail:
[email protected].
Copyright 9 2001 by W.B. Saunders Company
1524-153X/01/0304-00I 1535.00/0
doi:10.1053/otgn.2001.27773

Operative Techniques in General Surgery, Vol 3, No 4 (December), 2001: pp 283-290 283

284 Hughes and Moser

SURGICAL TECHNIQUE

Insertion of a Standard Jejunostomy Tube

~nt of Treitz
colon

roximal
for
Duodenum )my

f insertion of
hrough skin and
;m.

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erior epigastric
ssels

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/
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1 The jejunostomy tube is inserted through the anterior abdominal wall so that it
traverses the rectus abdominus muscle lateral to the epigastic vessels and inferior to the
transverse colon. After sterile preparation of the skin, the peritoneal cavity is entered
through a 5- to ]0-cm midline incision made approximately halfway between the
xiphoid process and the umbilicus. If the jejunostomy tube is being inserted at the
conclusion of another procedure, then any incision that provides adequate exposure to
the upper abdomen can be used. We avoid a left paramedian incision, because the tube
will exit the skin in close proximity to the wound, increasing the risk of wound
infection.
Open Jejunostomy 285

insertion
ostomy
thin
~ed pursestring

2 The abdomen should be explored to the extent allowed by the recision. The
ligament of Treitz is identified by following the proximal small bowel to the root of
the transverse mesocolon. If the patient has had previous abdominal surgery, then
the entire small bowel should be examined for potential obstructions to avoid
inserting a feeding tube proximal to an obstruction. Moreover, identifying the
ligament of Treitz in patients who have undergone multiple previous abdominal
operations is a challenge that should not be underestimated.
Minimizing the length of jejunum proximal to the je]unostomy tube decreases
the risk of small bowel volvulus around the insertion site. Therefore, the tube
should be inserted into the jejunum as close to the ligament of Treitz as possible
without placing the afferent loop of jejunum under tension when it is sutured to
the posterior abdominal wall. At the selected location, a silk pursestring suture is
placed in the antimesenteric wall of the jejunum. A separate stab wound is made
through the skin lateral to the epigastric vessels as described earlier, and the tube
is passed bluntly through the abdominal wall with a curved hemostat. The skin
incision should be of adequate size to allow drainage of the subcutaneous space
and minimize the risk of subcutaneous abscess or necrotizing fasciitis. A commer-
cially available 12 French Silastic or rubber catheter with multiple side holes may
be used as a feeding tube. We prefer Silastic tubes, because they are less prone to
clogging and are softer and more comfortable for the patient.
A hemostat is placed on the proximal end of the tube to prevent intraoperative
contamination of the operative field by enteric contents. An enterotomy is made
through the wall of the jejunum in the center of the previously placed pursestring
suture, and hemostasis is obtained with electrocautery. The tip of the feeding tube
is introduced through the enterotomy and advanced into the distal jejunum for a
distance of at least 20 cm. Care must be taken to ensure that the tube resides within
the lumen and not within a false submucosal tunnel.
286 Hughes and Moser

with

s placed
wing

Jejunostorr
exiting abdo~
wall via separ
stab wound

\,
\

3 and 4 The pursestring suture is drawn tight around the tube and tied. To minimize the risk of
peritoneal contamination by leaking intestinal contents, a seromuscular tunnel is then created using
interrupted sutures. This technique is attributed to Witzel. The feeding tube is gently invaginated into
the antemesenteric wall of the jejunum, using horizontally placed seromuscular sutures of nonabsorb-
able material. These sutures should be separated by 3-4 mm and create a tunnel approximately 2-3 cm
in length. While fashioning the seromuscular tunnel, the surgeon should compress the jejunum
proximal to the enterotomy site with the thumb and index finger at a point midway between the
mesentery and the antimesenteric portion of the bowel to prevent narrowing the lumen of the jejunum.
The final suture used to create the seromuscular tunnel should incorporate the jejunostomy feeding
tube to prevent migration or displacement of the tube in the postoperative period.
Open Jejunostomy 287

Jejunostomy tube secured to skin

abdominal
silk stay
sutures

5 Finally, the jejunum is secured to the anterior abdominal wall with

interrupted sutures. This maneuver further reduces the risk of small
bowel volvulus around the site of the jejunostomy tube. The tube is
securely anchored to the skin externally. The peritoneal cavity is irri-
gated before abdominal closure in the standard fashion. According to the
surgeon's preference, the jejunostomy tube may be connected to a bag
for gravity drainage. The jejunostomy tube and drainage system must be
securely taped to the patient's skin to prevent inadvertent dislodgement.

Insertion of a Transgastric Jejunostomy Tube

Transgastric jejunostomy feeding tube with

entry site in greater curvature of stomach
with pre-placed pursestdng sutures

Sj
6 A subxiphoid midline incision should be used to insert
a combination gastrojejunostomy tube. The greater curva-
ture of the stomach is grasped in an atraumatic fashion and
retracted inferiorly. The gastrostomy site should be located
in the body of the stomach along the greater curvature in a
position that will reach the anterior abdominal wall with-
out tension. Placing the gastrostomy too close to the pylo-
rus will result in gastric outlet obstruction when the bal-
loon of the gastrojejunostomy tube is inflated. Two
concentric seromuscular pursestring sutures are placed
around the identified gastrostomy site; the internal purse-
string should have a diameter of approximately 1.5 cm, and
the second should have a diameter of approximately 2 cm.
The tube should exit the abdominal wall lateral to the
epigastric vessels and at least two fingerbreadths below the
costal margin to prevent trauma to the intercostal nerves
and avoid irritation to the patient's rib margin. The skin is
incised sharply, and a tract through the fascia and rectus
abdominus muscle is created with a curved hemostat. The
skin incision should be large enough to drain the subcuta-
neous space and minimize the risk of subcutaneous abscess
or necrotizing fasciitis.
i f
288 Hughes and Moser

Insertion of gastrojejunostomy
tube via guide through pylorus
and duodenum into jejunum
Balloon and
drainage ports
o be placed in
stomach

Digital protection against

perfoLation of duodenum
withadvancement
~ , : . . ' ~ of
tube

\
L " ~ - Ligament of Treitz

Ports in proximal
jejunum for feeding

7 The gastrojejunostomy tube is passed into the peritoneal cavity and loaded into a
rigid plastic introducer sheath used as a guide for passing the pliable tube through the
pylorus. This procedure is simplified by using a sterile water-soluble lubricant. A
gastrotomy is created in the center of the concentric pursestring sutures, and hemosta-
sis is obtained with electrocautery. The tube is inserted through the gastrotomy and
guided through the pylorus. Placing the left hand at the junction of the first and second
portions of the duodenum facilitates passage of the tube around the sweep of the
duodenum and prevents inadvertent perforation. The tube is advanced until it is
palpable within the lumen of the jejunum distal to the ligament of Treitz, and the plastic
guide is then carefully removed so as not to dislodge the tube.
Open Jejunostomy 289

Balloon inflation port

Tube in place with balloon

inflated - - " . . . . . . . . . . . .
\ Gastric and jejunal
ports
sutures s,

8 After confirming that the retaining balloon resides within the stomach,
the balloon is inflated according to the manufacturer's recommendations. The
concentric pursestring sutures are drawn secure and tied.

Stay sutures placed for securing stomach to abdominal

wall around tube

9 The gastric wall is sutured to the anterior ab-

dominal wall with a number of interrupted sutures,
using the seromuscular layer of the stomach and the
posterior rectus sheath with its overlying perito-
neum. These sutures are placed circumferentially
around the gastrostomy site. Care must be exer-
cised to prevent puncturing the gastrojejunostomy
balloon. Positioning the balloon away from the gas-
tric wall during the placement of these sutures will
minimize the risk of this frustrating technical error.
The sutures are then tied, anchoring the serosa of
the stomach securely to the anterior abdominal
wall. Additional sutures are used to anchor the tube
to the skin externally. Most manufacturers provide
a T-bar or disc to facilitate securing the tube to the
s~in. The abdomen is irrigated and closed in stan-
dard fashion, and the gastric and jejunal ports of the
tube are connected to separate bags for dependent
drainage.
290 Hughes and Moser

Postoperative Management and Tube Care drain. The tube should be securely taped to the skin when
sutures must be removed. Operative exploration of the
Feeding tubes should be left to dependent drainage for
subcutaneous tissues and fascia is warranted if skin ery-
approximately 24 hours after the procedure. Nasogastric
thema does not resolve after the institution of antibiotic
decompression may be necessary in some patients if gas-
tric emptying difficulties are anticipated and the risk of therapy.
Significant leakage of enteric contents around a jeju-
aspiration is high. Many surgeons prefer to begin infusing
nostomy tube is a difficult problem to manage. It usually
10% dextrose solution at a rate of 20 ml/hr on the first
results from necrosis of the skin around the tube and
postoperative day to prevent tube clogging. Nutrient
enlargement of the tube entry wound. This problem is
feedings are infused on postoperative day two and ad-
managed using a small-bore catheter with a balloon, pref-
vanced to the desired goal depending on the patient's
tolerance. erably one made of Silastic if available. The tube is passed
into the jejunum, and the balloon is inflated to 2.0-2.5 ml
A common complication of feeding tube placement is
with water to avoid obstructing the proximal gastrointes-
inadvertent postoperative dislodgement of the tube. It is
tinal tract. The tube is then held vertically to the skin with
important to remember that most patients requiring these
a (verticle) tube holder device. The skin is treated with
procedures have multiple risk factors for impaired wound
Desitin cream to allow the inflammation caused by en-
healing and depressed mental status. The development of
teric leakage to subside. If necessary, a stoma device can
a mature transabdominal tract and adhesion of the jeju-
be used to catch enteric contents and prevent skin irrita-
n u m or stomach to the anterior abdominal wall usually
tion while the tract inflammation resolves. With this tech-
takes six weeks. If the jejunostomy tube becomes dis-
lodged or obstructed after this time, it usually can be nique, tube revision is rarely necessary. Radiographic
replaced at the bedside or in the office. Aspiration of evaluation to identify or rule out distal obstruction
should be completed before revision.
intestinal effluent suggests, but does not guarantee, place-
ment into the lumen. Clinical judgment must be used
regarding the need to confirm placement of the tube Conclusions
within the lumen of the small intestine under these cir- Jejunostomy feeding tubes are an important tool for pro-
cumstances. The installation of water-soluble contrast viding enteral nutrition in selected patients. Complica-
under fluoroscopy is recommended. The tube must be tions associated with jejunostomy feeding tubes can be
replaced promptly after it becomes dislodged, because the serious and usually result from a lapse in surgical tech-
tract will often close within 24 hours. nique. The combination gastrojejunostomy feeding tube
If the tube becomes dislodged or obstructed before a has a number of advantages over standard jejunostomy
mature tract has formed, it is reasonable for an experb tubes and should be used whenever possible.
enced surgeon to replace the tube at the bedside using a
smaller-diameter tube even if the tract has not had time to REFERENCES
mature. Radiographic confirmation of the tube's position
must be obtained immediately. An alternative and poten- 1. Heslin MJ, Latkany L, Leung D, et ah A prospective, randomized
trial of early enteral feeding after resection of upper gastrointestinal
tially safer option is to have on interventional radiologist
malignancy. Ann Surg 226:567-577, 1997
replace the tube using a Seldinger technique with fluoro- 2. Gore DC, DeLegge M, Gervin A, et ah Surgically placed gastro-
scopic guidance. jejunostomy tubes have fewer complications compared to feeding
As a result of a foreign body reaction, a small rim of jejunostomy tubes. J Am Coll Nutr 15:144-146, 1996
erythema about the tube's entry site through the skin is 3. Bergstrom LR, Larson D, Zinsmeister AR, et ah Utilization and
not unusual. The accumulation of fibrinous exudate at outcomes of surgical gastrostomies and jejunostomies in an era of
percutaneous endoscopic gastrostomy: A population-based study.
the tube interface with the skin is also common. Local Mayo Clin Proc 70:829-836, 1995
hygiene is maintained with a cotton-tipped applicator 4. Stiegmann GV, GoffJS, Silas D, et ah Endoscopic versus operative
using a dilute solution of hydrogen peroxide or chlo- gastrostomy: Final results of a prospective randomized trial. Gas-
rhexidine. Increasing discomfort or spreading erythema trointest Endosc 36:1-5, 1990
must be evaluated thoroughly, however, because celluli- 5. Faries MB, Rombeau JL: Use of gastrostomy and combined gastroje-
junostomy tubes for enteral feeding. World J Surg 23:603-607,
tis, subcutaneous abscess, and necrotizing fasciitis are
1999
common complications of enteral feeding tubes. We ad- 6. Tompkins RK, Kraft AR, ZoUinger RM: Double-lumen gastrojeju-
vise removing sutures around the tube under these cir- nostomy tube for simplified postoperative management. Arch Surg
cumstances to ensure that infected fluid collections can 105:121-122, 1972