Critical analysis of feeding jejunostomy following resection of upper gastrointestinal malignancies

AIM To assess nutritional recovery,particularly regarding feeding jejunostomy tube(FJT)utilization,following upper gastrointestinal resection for malignancy. METHODS A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy(subtotal or total)for cancer with curative intent,from January 2001 to June 2014. Patient demographics,the approach to esophagectomy,the extent of gastrectomy,FJT placement and utilization at discharge,administration of parenteral nutrition(PN),and complications were evaluated. All patients were followed for at least ninety days or until death.RESULTS The 287 patients underwent upper GI resection,comprised of 182 esophagectomy(n=107 transhiatal,58.7%; n=56 Ivor-Lewis,30.7%)and 105 gastrectomy [n=63 subtotal(SG),60.0%; n=42 total(TG),40.0%]. 181 of 182 esophagectomy patients underwent FJT,compared with 47 of 105 gastrectomy patients(99.5% vs 44.8%,P < 0.0001),of whom most had undergone TG(n=39,92.9% vs n=8 SG,12.9%,P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups(14.7 d vs 17.1 d,P=0.076). Upon discharge,87 esophagectomy patients(48.1%)were taking enteral feeds,with 53(29.3%)fully and 34(18.8%)partially dependent. Meanwhile,20 of 39 TG patients(51.3%)were either fully(n=3,7.7%)or partially(n=17,43.6%)dependent on tube feeds,compared with 5 of 8 SG patients(10.6%),all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients(6.4% vs 29.3%,P=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy(n=11,23.4% vs n=7,3.9%,P=0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group(n=6),all after TG,compared to 1 esophagectomy patient(12.8% vs 0.6%,P=0.0003). Six of 7 patients(85.7%)who experienced tube-related complications required PN.CONCLUSION Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas

Objective： Patients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self- controlled study was to examine the effect of jejunostomy tube feeding （JTF） and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer. Methods： All consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy plaeement were included from a prospective single-center database （2003-2014）. Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastreetomy. Results： Of 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range （IQR）, 10-55 d]. Jejunostomy-related complieations occurred in 11 （17%） patients, including skin leakage （n=3） and peritoneal leakage （n=2）, luxation （n=3）, occlusion （n=2）, infection （n=l） and torsion （n=l）. In 2 （3%） patients, a reoperation was needed due to jejtmostomy-related complications. The mean preoperative weight of patients was 71.8 kg （100%）, and remained stable during JTF （73.9 kg, 103%, P=0.331）. After JTF was stopped, the mean weight of patients decreased to 64.9 kg （90%） at 12 months after surgery （P〈0.001）. A high preoperative body mass index （BMI） （〉_25 kg/m2） was associated with high postoperative weight loss compared to patients with a low BMI （〈25 kg/m2） （16.3% vs. 8.6%, P=0.016）. Conclusions： JTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Percutaneous endoscopic gastrostomy and jejunostomy:Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight.Therefore,oral feeding is the main approach for such patients.When physiological nutrition is not possible,positioning of a nasogastric,nasojejunal tube,or other percutaneous devices may be feasible alternatives.Creating a percutaneous endoscopic gastrostomy(PEG)is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk.Many diseases require nutritional support by PEG,with neurological,oncological,and catabolic diseases being the most common.PEG can be performed endoscopically by various techniques,radiologically or surgically,with different outcomes and related adverse events(AEs).Moreover,some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent.These conditions highlight many ethical problems that become difficult to manage as treatment progresses.The aim of this manuscript is to review all current endoscopic techniques for percutaneous access,their indications,postprocedural follow-up,and AEs.

Impact of jejunostomy during esophagectomy for cancer on health related quality of life

Background： The aim of this study was to evaluate the impact of jejunostomy during esophagectomy for cancer on postoperative health-related quality of life（HRQL）.Methods： We evaluate all consecutive patients who underwent esophagectomy for cancer at the surgical oncology unit of the Veneto Institute of Oncology（IOV-IRCCS） between January 2008 and March 2014. The primary outcome was HRQL, which was assessed using nine scales of EORTC C30 and OES18 questionnaires. General linear models were estimated to evaluate mean score difference（MD） of each selected scale in patients with and without jejunostomy, adjusting for clinically relevant confounders. The secondary outcomes were morbidity, hospital stay, postoperative weight loss and postoperative albumin impairment. Results： Jejunostomy was performed in 40 on 109 patients（41.3%） who participated in quality of life investigation. A clinically and statistically significantly worse eating at admission（P=0.009） became not clinically significant at 3 months after surgery（MD =9.1）. Jejunostomy was associated to clinically and statistically significantly poorer emotional function（EF） at 3 months after surgery（MD =-15.6; P=0.04）. Hospital stay was longer in jejunostomy group（median, 20 vs. 17 days, P=0.02）.Conclusions： In our series patients who had a jejunostomy during esophagectomy had been selected for their risk for postoperative complication. However, their postoperative outcome was actually similar compared to those without jejunostomy. Nevertheless, jejunostomy was associated to clinically and statistically significantly poorer EF at 3 months after surgery. Therefore, patient candidate to esophagectomy and feeding jejunostomy should receive additional psychological support.

Jejunostomy Feeding Tube Placement in Gastrectomy Procedures: A Systematic Review

Many nutritional interventions have been developed to improve nutritional outcomes following upper gastrointestinal surgery. The aim of this systematic review was to investigate whether or not the routine use of intraoperative jejunostomy feeding tubes in partial and total gastrectomy procedures is warranted when assessing complications and nutritional benefits such as improved chemotherapy tolerance. An electronic search of MEDLINE, Web of Science, Embase and CINAHL databases was performed to identify studies which reported complications and/or post-operative outcomes of patients who received an intraoperative jejunostomy feeding tube in gastrectomy procedures. Five articles met the inclusion criteria (n = 636) with four retrospective cohort studies and one RCT. Studies varied in regards to the complications and nutritional outcomes reported. Jejunostomy feeding tube insertion may carry a risk of increased infectious complications but appears to reduce patient post-operative weight-loss and may improve chemotherapy tolerance. Due to the lack of high-quality studies, it is unclear if the routine use of an intraoperative jejunostomy feeding tube is indicated for all patients undergoing gastrectomy procedures or only those at a high-risk of post-operative malnutrition. More comprehensive research is recommended, particularly on the usefulness of home enteral nutrition post-gastrectomy.

Jejunostomy in the palliative treatment of gastric cancer:A clinical prognostic score

BACKGROUND Clinical stage IV gastric cancer(GC)may need palliative procedures in the presence of symptoms such as obstruction.When palliative resection is not possible,jejunostomy is one of the options.However,the limited survival of these patients raises doubts about who benefits from this procedure.AIM To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.METHODS We performed a retrospective analysis of Stage IV GC who underwent jejunostomy.Eleven preoperative clinical variables were selected to define the score categories,with 90-d mortality as the main outcome.After randomization,patients were divided equally into two groups:Development(J1)and validation(J2).The following variables were used:Age,sex,body mass index(BMI),American Society of Anesthesiologists classification(ASA),Charlson Comorbidity index(CCI),hemoglobin levels,albumin levels,neutrophil-lymphocyte ratio(NLR),tumor size,presence of ascites by computed tomography(CT),and the number of disease sites.The score performance metric was determined by the area under the receiver operating characteristic(ROC)curve(AUC)to define low and high-risk groups.RESULTS Of the 363 patients with clinical stage IVCG,80(22%)patients underwent jejunostomy.Patients were predominantly male(62.5%)with a mean age of 62.4 years old.After randomization,the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score.The high NLR had the highest value.The ROC curve derived from these pooled parameters had an AUC of 0.712(95%CI:0.537–0.887,P=0.022)to define risk groups.In the validation cohort,the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756,(95%CI:0.598–0.915,P=0.006).According to the cutoff,in the validation cohort BMI less than 18.5 kg/m2(P<0.001),CCI≥1(P=0.001),ASA III/IV(P=0.002),high NLR(P=0.012),and the presence of ascites on CT exam(P=0.004)were significantly associated with the high-risk group.The risk groups showed a significant association with first-line(P=0.012),second-line chemotherapy(P=0.009),30-d(P=0.013),and 90-d mortality(P<0.001).CONCLUSION The scoring system developed with 11 variables related to patient’s performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Small bowel intussusception in a child following feeding jejunostomy: A rare case with review of literature

Jejuno-jejunal intussusception is a rare complication of feeding jejunostomy tube placement. A case of one year old child who underwent gastric pull-up for complicated tracheo-esophageal fistula had jejuno-jejunal intussusception induced by Witzel's feeding jejunostomy tube;is discussed with review of literature.

Jejunojejunal Intussusception following Jejunostomy

Intussusception is an invagination of a segment of the gastrointestinal tract into an adjacent one. Jejunojejunal intussusception is a rare complication of jejunostomy tube placement with an incidence of 1%. We are reporting a case of 35-year-old man who was suffering from severe oral, lesions due to Ingestion of acide agents. He received Witzel jejunostomy for early feeding. Ileus developed postoperatively and plain X-ray of the abdomen showed distended small bowel loop. Abdominal computed tomography revealed target sign as well as the feeding tube in a dilated jejunum and intussusception was diagnosed. Exploratory laparotomy was required due to failure of expectant therapy. Reduction of intussusception was done during exploratory laparotomy. The jejunostomy feeding was continued and the postoperative course was uneventful.

Short-term effects of supplementary feeding with enteral nutrition via jejunostomy catheter on post-gastrectomy gastric cancer patients

Background Most gastric cancer patients who undergo gastrectomy develop malnutrition. It is, therefore, crucial to establish an effective means to provide nutrition for these patients. To perform home enteral nutrition （EN） to ensure adequate nutritional intake in gastric cancer patients, we placed a jejunostomy catheter during gastric surgery. Most patients showed improved nutritional status. Methods Twenty-nine inpatients at our hospital underwent radical gastrectomy and jejunostomy from December 2002 to December 2007 and were designated as the jejunostomy group, and 32 matched patients without a jejunostomy tube were designated as the tube-free group. The jejunostomy group was treated with EN from 72 hours to 3 months postoperatively. The tube-free group did not receive EN. Data including preoperative and postoperative body weight, body mass index （BMI）, nutrition risk screening （NRS） score, Karnofsky performance score （KPS）, and laboratory biochemical indicators were documented respectively and compared. Results Compared with preoperative week 1, both groups showed decreased body weight and BMI at 3 months postoperatively. The weight loss in the jejunostomy group （（7.1±3.3） kg） was significantly less than that in the tube-free group （（9.9±3.1） kg）. Similarly, BMI decreased by （2.4±1.0） kg/m2 in the jejunostomy group, which was significantly less than in the tube-free group （（3.2±0.9） kg/m2）. The number of patients with postoperative NRS 〉3 was decreased in the jejunostomy group, but was increased in the tube-free group, and this difference was significant. There were no significant differences between the two groups in total lymphocyte count, hemoglobin, albumin and prealbumin, and adverse drug effects. Conclusions Short-term （3 months） EN supplementation via jejunostomy tube can reduce the risk of malnutrition and weight loss, and improve tolerance of chemotherapy. Tube feeding is reliable for achieving these goals because it is not important whether or not the oatients have appetites.

Endoscopist's approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis.This article reviews the endoscopist's approach to manage nutrition in such cases.Enteral feeding has been clearly validated as the preferred route of feeding,and should be started early on admission.Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction.Moreover,nasogastric feeding is safe and as effective as nasojejunal feeding.If a prolonged course of enteral feeding(>30d) is required,endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Surgical Selection for Late Pancreatic Head Carcinoma without Gastric Outlet Obstruction

The effects of different surgical procedures for late pancreatic head carcinoma without gas- tric outlet obstruction were explored in order to provide theoretical basis to select a suitable operation for these patients. The clinical data of 441 cases of late pancreatic head carcinoma without gastric outlet obstruction were retrospectively analyzed. All patients were divided into 4 groups based on different surgical procedures： group A （101 cases） subjected to Roux-en-Y cholecystojejunostomy; group B （133 cases） undergoing Roux-en-Y choledochojejunostomy; group C （83 cases） given Roux-en-Y chole- cystojejunostomy combined with gastrojejunostomy; group D （124 cases） receiving Roux-en-Y chole- dochojejunostomy combined with gastrojejunostomy. Therapeutic efficacy in each group was evaluated comparatively. Both groups B and D had a lower rate of postoperative obstructive jaundice than groups A and C separately （P〈0.05 for all）. The data of mean life span showed that both groups B and D had a lower survival rate than groups A and C separately （P〈0.05 for all）. The incidence of postoperative gas- tric outlet obstruction in groups A and B was higher than that in groups C and D separately （P〈0.05 for all）. The gastrojejunostomy had no impacts on the mean life span, and there was no statistically signifi- cant difference in complications, average hospital stay （days） and median survival among four groups （P〉0.05）. For the late pancreatic head carcinoma without gastric outlet obstruction, Roux-en-~ chole- dochojejunostomy is effective for the reduction of icteric index and the incidence of recurrent jaundice, also offers an opportunity for prolonged survival. Combined use of prophylactic Roux-en-Y gastrojeju- nostomy during surgical biliary drainage is safe for advanced pancreatic carcinoma with obstructive jaundice, which can decrease the incidence of postoperative gastric outlet obstruction, and has important implications for improving outcomes.

Optimal timing and route of nutritional support after esophagectomy: A review of the literature

Some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy.Variation in practices during the perioperative period exists including the type of nutrition started,the delivery route,and its timing.Adequate nutrition is essential for this patient population as these patients often present with weight loss and have altered eating patterns after surgery,which can affect their ability to regain or maintain weight.Methods of feeding after an esophagectomy include total parenteral nutrition,nasoduodenal/nasojejunal tube feeding,jejunostomy tube feeding,and oral feeding.Recent evidence suggests that early oral feeding is associated with shorter LOS,faster return of bowel function,and improved quality of life.Enhanced recovery pathways after surgery pathways after esophagectomy with a component of early oral feeding also seem to be safe,feasible,and cost-effective,albeit with limited data.However,data on anastomotic leaks is mixed,and some studies suggest that the incidence of leaks may be higher with early oral feeding.This risk of anastomotic leak with early feeding may be heavily modulated by surgical approach.No definitive data is currently available to definitively answer this question,and further studies should look at how these early feeding regimens vary by surgical technique.This review aims to discuss the existing literature on the optimal route and timing of feeding after esophagectomy.

Endoscopic placement of enteral feeding tubes

Malnutrition is common in patients with acute and chronic illness.Nutritional management of these malnourished patients is an essential part of healthcare.Enteral feeding is one component of nutritional support.It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract(GIT).This method of nutritional support has undergone progression over recent times.The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology.Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT.This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.

Clinical Outcome of Early Enteral Feeding on Patients Post Esophagectomy

Objectives: Aim of our work is to study the effect of early enteral feeding through either nasoentral or feeding jejunostomy tube post esophagectomy on patients recovery and hospital stay. Background: Postoperative nutrition is a well known aspect of care in recent years and has been shown to decrease the incidence of complications and hospital stay. Enteral nutrition has been shown to be superior to parenteral nutrition as it is more physiological, safer, cheaper and early enteral nutrition has been clearly confirmed to reduce postoperative morbidity. Methods: This is randomized combined retrospective and prospective study that is conducted in surgical oncology department, South Egypt cancer institute, Assiut University;from October 2012 to October 2016. Patients in this study were divided into two groups: group 1 includes patients with feeding jejunostomy and group 2 is patients with nasoenteral tube. Results: 25 Patients included in this study (19 males & 6 females). All cases were primarily diagnosed as esophageal cancer, middle and lower 1/3 esophagus or proximal gastric carcinoma infiltrating cardia by clinical data associated with abdominal sonar and/or C.T scan and upper endoscopy with biopsy. There was no significant difference in catheter related complications (P value 0.238). There was no operative mortality. Conclusion: Early postoperative enteral nutrition was feasible and safe for patients undergoing esophagectomy. There is no significant difference between NE and FJ. Enteral nutrition either through nasoenteral or feeding jejunostomy is an effective method for postoperative nutritional support in this type of major surgery.

Incidence of Ostomies in Tertiary Care Teaching Institution

A retrospective observational study was conducted at Saveetha medical college and hospital, over 2 years, from January 2017-January 2019. A total of 29 patients with ostomies were included in this study. Information regarding the types and indications of the ostomies were collected from the hospital records. The collected data were analyzed using Microsoft Excel, and represented by tables and charts. Majority of patients were the males and the predominant age group was 51 - 60 years old. The objective of the present study was to classify ostomies based on organs and to analyze the aetiology for creating those ostomies.