29. Placement of Jejunostomy Tube

Bruce David Schirmer, M.D., F.A.C.S.

A. Indications

Placement of a jejunostomy tube is indicated when the proximal gastrointestinal system is unable to be used safely as a route for delivery of enteral nutri- tion, but intestinal function is otherwise unimpaired. Tube placement may be the sole indication for the operation, or it may accompany another procedure. Where tube placement is the sole procedure, the indications include the following: 1. Documented gastroparesis with nutritional compromise 2. Proximal gastrointestinal obstruction precluding percutaneous gastrostomy placement 3. Speciﬁc requirements for a jejunostomy rather than a gastrostomy, such as for the delivery of L-DOPA to treat Parkinson’s disease (where the medication is less effective if exposed to an acid environment). Jejunostomy tube placement may also be incorporated as part of a larger operation. Common indications for its placement regardless of using celiotomy or laparoscopic approaches include the following: 1. Major upper gastrointestinal reconstruction where postoperative anastomotic problem, if present, will preclude enteral feeding. Examples include esophagogastrostomy, total gastrectomy, and pancreaticoduodenectomy. 2. Operations to treat pancreatic or duodenal trauma, and severe pancreatitis.

B. Patient Positioning and Room Setup

1. Position the patient supine. Place a monitor near the patient’s left shoulder. 2. The surgeon stands by the patient’s right hip, with the camera opera- tor on the same side. The assistant may stand on the opposite side.

C. Trocar Position and Instrumentation

1. Place the initial trocar in the infraumbilical region. Where jejunostomy accompanies another procedure, this may already have occurred. 29. Placement of the Jejunostomy Tube 343

Figure 29.1. Trocar placement for laparoscopic jejunostomy.

2. Place a second trocar in the left lower quadrant. This must be of suf- ficient size to allow intracorporeal suturing (10–12mm, or smaller depending upon instrumentation and needle size. 3. Place the final trocar in the right upper quadrant, not far from the midline, in a comfortable position for use by the surgeon’s left hand (Fig. 29.1). 4. In addition to standard laparoscopic instruments, a 30-degree laparoscope, two needle holders, and a pair of atraumatic bowel graspers are needed. 5. A commercially available gastrostomy or jejunostomy kit is helpful: a Silastic catheter with an inflatable balloon, separate channels for decompression and feeding, and an outer bolster to secure the catheter to the skin. Serial dilators and a percutaneous needle and guidewire for tube insertion via a Seldinger technique are also required for the technique described here. 344 B.D. Schirmer D. Technique of Jejunostomy Tube Placement

1. As described in Chapter 28, initial Trendelenburg positioning with retraction of the transverse colon helps visualize the ligament of Treitz. It is essential that the proximal jejunum be clearly identified. 2. Once the ligament of Treitz is seen, place the patient in slight reverse Trendelenburg to allow easier tracing of the bowel and to permit the remainder of the distal intestine to fall away. Trace the proximal jejunum to a convenient point, usually 1 to 2 feet beyond the ligament, where the bowel can be elevated to touch the left upper quadrant abdominal wall. 3. Determine the location for the tube site in the left upper quadrant (See Chapter 24 for more information about tube siting.) 4. Place four anchoring sutures in a diamond configuration around this site. The author uses 3-0 nylon suture on a straight needle to pierce the abdominal wall, and a laparoscopic needle holder to then pull the needle into the abdominal cavity. 5. Take a seromuscular bite of the antimesenteric border of the intestine, in a position corresponding to the diamond configuration proposed for the suture placement (Fig. 29.2).

Figure 29.2. The anchoring sutures are being placed. The suture is passed through the abdominal wall, a seromuscular bite of intestine is taken, and the suture is then passed out of the abdomen. Four sutures are placed in a diamond- shaped conﬁguration, providing both retraction and anchoring. 29. Placement of the Jejunostomy Tube 345

Figure 29.3. Passing one of the dilators through the abdominal wall and into the lumen of the jejunum. Care is taken to pass the dilator just into the lumen of the bowel (under visual laparoscopic control), not far enough to risk posterior intestinal wall perforation.

6. Pass the needle out through the abdominal wall adjacent to its entry site. Do not tie these sutures at this point. 7. If desired, additional absorbable 3-0 braided sutures may be placed (and subsequently tied intracorporeally) to anchor the bowel wall to the underside of the abdominal wall and safeguard against leakage. 8. Insert the jejunostomy tube via a Seldinger technique. a. Pass the percutaneous needle through the abdominal wall in the center of the diamond configuration of anchoring sutures. b. Take care to position the bowel and advance the needle only far enough to penetrate into the lumen. Do not allow the needle to pierce the back wall. c. Pass the guidewire through the needle, into the lumen of the jejunum. Laparoscopic visualization of intestinal movement from wire manipulation is used to confirm the wire’s position within the lumen of the bowel. Turn the bowel and inspect it to confirm that penetration or injury to the back wall has not occurred. Repo- sitioning the laparoscope to the left lower quadrant trocar facili- tates this maneuver. d. With the guidewire in place, enlarge the skin site with a knife and pass serial dilators percutaneously to dilate the track for the tube (Fig. 29.3). Take care to avoid excessive passage of the stiff 346 B.D. Schirmer

dilators into the jejunum; posterior bowel wall perforation may result. 9. Once the largest of the dilators has been passed and withdrawn, pass the tube into the jejunum under laparoscopic vision, using the stent available in the kit (Fig. 29.4). Remove the stent. 10. Tie the anchoring sutures. If additional intracorporeal sutures are needed, these may be placed and tied at this point rather than earlier. 11. Inflate the balloon with 3mL of saline. Overdistention of the balloon may cause intestinal obstruction. Position the catheter so that the balloon is snug against the abdominal wall within the lumen of the jejunum. 12. Adjust the outer bolster to the skin level and secure it with nylon skin sutures. 13. Test the catheter for ease of gravitational flow of saline into the jejunum, and observe the resulting flow into the bowel with the laparoscope. Methylene blue may be used if there is concern about leakage. 14. Secure the four anchoring sutures without excessive skin trauma by passing the needle through a small cotton dissector roll, both before entering and after exiting the abdominal wall. This roll serves as a bolster to prevent skin damage from the suture (Fig. 29.5).

Figure 29.4. Passing the Silastic feeding jejunostomy tube into the lumen of the jejunum and tying the sutures. 29. Placement of the Jejunostomy Tube 347

Figure 29.5. The abdominal wall upon completion of the procedure. The external and anchoring sutures are secured to the skin.

E. Complications

1. Intestinal perforation a. Cause and prevention. Intestinal perforation may result if the guidewire or dilator is passed too far, injuring the back wall. Careful attention to technique as described should prevent this complication. b. Recognition and management. Intraoperative recognition is the goal; this requires careful intraoperative inspection of the posterior intestinal wall. Any injuries that are recognized need imme- diate suture repair and confirmation that the repair is watertight. Absence of leakage of methylene blue from the repaired site pro- vides good reassurance that the repair is sound. 2. Intestinal obstruction a. Cause and prevention. The most common cause of postoperative intestinal obstruction is overinflation of the intraluminal balloon. To prevent this problem, do not use more than 3 (or at most 4) mL of saline. b. Recognition and management. Maintain a high index of suspicion for this problem. Balloon deflation is both diagnostic and therapeutic. 348 B.D. Schirmer

3. Leakage from balloon site a. Cause and prevention. The most likely causes are inadequate fixation of the bowel to the abdominal wall or an unrecognized perforation. Prevention is through careful technique. b. Recognition and management. Index of suspicion for this problem should be high when signs and symptoms of peritonitis result postoperatively. A water-soluble contrast study through the tube is indicated to help determine whether a leak is present. If the study is negative and strong suspicion still exists that the tube is the source of the peritonitis, reexploration is indicated. If a tube site leak is identified, it must be repaired operatively with sutures or even reconstruction if needed. On occasion, the leak may result from balloon deflation, and balloon reinflation to the appropriate size should be performed and the contrast study repeated to determine whether the leak has been corrected. 4. Dislodgment of catheter a. Cause and prevention. Most often a catheter is dislodged when a disoriented patient pulls on the tube. When the patient’s condi- tion predisposes to such action, protect all but the very end of the tube under an occlusive dressing or abdominal binder. Make con- nections to external feeding or drainage tubes loose so that a pull on the tube results in disruption of the external connection rather than tube dislodgment. Careful intraoperative securing of the tube and postoperative protective dressing should prevent this problem. b. Recognition and management. Recognition is usually obvious clinically. Management depends on the time course after surgery and after tube dislodgment. In all cases, an attempt to replace the tube into the intestinal lumen should be made immediately. If this is felt to be successful, radiographic confirmation of correct tube positioning and absence of tube site leak is mandatory in the first 10 days after surgery or if questions about tube position remain at any time thereafter. If the tube cannot be replaced, and the patient is less than 10 days from tube placement, emergent reoperation for tube replacement and to prevent potential intraperi- toneal contamination is indicated. If the tube has been in place for more than 10 days, elective reoperation to replace it may be performed.

F. Selected References

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