Emergency High-Loop Jejunostomy As Enteral Nutrition Access: A Simple and Safe Method
By Pacelli, Fabio Rotondi, Fabio; Rosa, Fausto; Bossola, Maurizio; Papa, Valerio; Tortorelli, Antonio Pio; Sollazzi, Liliana; Doglietto, Giovanni Battista
ABSTRACT. Background: Emergency high-loop jejunostomies are seldom used for nutrition access in the clinical practice. Methods: This paper describes the results of a simple and safe technique that uses emergency high-loop jejunostomy as an enteral feeding access. A feeding tube is inserted into the efferent loop of the jejunostomy and then subcutaneously tunneled. In this way, whenever it becomes necessary, the bag collecting fluids from the afferent loop can be changed without removing the tube, which remains permanently inserted into the efferent loop and secured to the skin in order to avoid displacements. Results: Twenty-nine patients with high-loop jejunostomy were consecutively treated with the described technique during the period 2000-2006. The mean distance between the ligament of Treitz and tube was 38.3 +- 16.2 cm. After an induction period, all patients received full-strength enteral nutrition and were discharged after a mean of 25.1 +- 19.5 days of treatment. All patients were subsequently readmitted to our unit, and their ostomies were successfully closed. No major early and late complications were observed; particularly, no patient experienced local or systemic septic complications. Conclusion: From the analysis of our results, the described method for delivering enteral nutrition through an emergency high-loop ostomy proves easy to apply and clinically effective. Enteral nutrition can be started as soon as possible after operation through the efferent loop of the ostomy; the management of the jejunostomy is simple and safe, with no additional discomfort for the patients. (Journal of Parenteral and Enteral Nutrition 32:94-97, 2008) Although strategically located in the digestive tract, emergency loop jejunostomies are seldom used for nutrition access in clinical practice. In fact, the necessity of repeated bag changes, due to the high output from the afferent loop, makes use of the efferent loop as an enteral access rather difficult. From a practical point of view, the feeding tube must cross the bag to enter the efferent loop, thus creating a risk of continuous spillage of intestinal fluids out of the bag, with significant discomfort for the patient, and complex nursing management.
For such reasons, in a great majority of cases, nutrition requirements are met by parenteral nutrition (PN) because for a long time patients do not use their digestive tract, either proximally (not to increase the output from the afferent loop) or distally (as a consequence of the difficulties in using the efferent loop for nutrition access).
The aim of the study is to report the technique and results of a simple method for delivering enteral nutrition through emergency high-loop jejunostomy, used as nutrition access.
MATERIALS AND METHODS
Between 2000 and 2006, 29 patients with emergency high-loop jejunostomy were treated according to the described technique (Table I).
Twenty-one patients were operated at our unit in an emergency setting, for intra-abdominal infection (both community-acquired, n = 10; and postoperative, n = 11). In all cases, at the end of the emergency operation a 10-12 Fr silicone or polyurethane catheter (Vygon Laboratories, Ecouen, France) was inserted into the efferent loop of jejunostomy, at least 20 cm from the entrance, and thereafter it was subcutaneously tunneled under the skin for at least 10 cm from the cutaneous margin of ostomy, using an Alene needle (Figure 1). The catheter was finally anchored to the skin with interrupted sutures of 2/0 silk.
Eight additional patients, transferred from other institutions after receiving an emergency operation for intra-abdominal infection, were treated with the same procedure, performed during the postoperative period under local anesthesia and fluoroscopy.
RESULTS
Of the 29 patients, 15 were men and 14 women. The mean age was 48.8 years (range, 22-72). The mean distance between the ligament of Treitz and tube was 38.3 +- 16.2 cm.
Enteral nutrition was started after the first bowel movements had appeared again (mean time of the first bowel movement was after 3.6 days [range, 2-7]; after an induction time, all patients received a full-strength semielemental diet, (80-125 mL/h according to patient’s weight).
TABLE I
Patients’ characteristics
FIGURE 1. Feeding jejunostomy: personal technique. A, The feeding tube is positioned in the efferent loop of the jejunostomy; the extreme tip of the catheter is fixed onto an Alene needle. B, The Alene needle is inserted in the subcutaneous layer, starting from the cutaneous margin of the ostomy, and begins the tunnelization. C, The tunnelization is completed. D, Arrow indicates the positioned floating flange for connecting the bag (Hollister Inc, Libertyville, IL). E, F, The procedure is completed. Sagittal (E) and frontal (F) views.
The mean duration of treatment in the hospital was 25.1 +- 19.5 days. Enteral nutrition was then continued at home for a mean of 53.2 +- 8.4 days. The overall duration of treatment was 78.3 +- 18.3 days. In all cases, intestinal continuity was successfully restored.
Patients experienced no major complications due to tunneled feeding tube; in particular, no septic complications were observed in peristomal side or in the subcutaneous tunnel. Two patients experienced tube displacement, which required reinsertion under fluoroscopy.
DISCUSSION
Although in the majority of surgical patients the digestive tract is the preferred route for nutrition treatment, in the case of high- loop jejunostomy (frequently performed during an emergency operation for intra-abdominal infection)1 enteral nutrition is seldom used. In fact, the high output of these ostomies virtually precludes oral feeding, thus causing long-term PN to be inevitably chosen, despite the risk of septic complications of central venous catheterization.2 Moreover, the use of excluded bowel tract for enteral nutrition, through the efferent loop of the ostomy, may be difficult from a practical point of view. For such reasons, despite the increased nutrition demand during the postoperative period, many patients do not use their digestive tract, either proximally or distally to the small bowel ostomy, for a long time.
This paper proposes a simple and effective method for delivering enteral nutrition in patients with emergency high-loop jejunostomy. In fact, the subcutaneous tunneled feeding tube does not interfere with management of the drainable pouch. Therefore, the bag can be changed whenever necessary, without removing the feeding tube, which remains permanently inserted into the bowel and secured to the skin in order to avoid displacements. Moreover, from the surgical point of view, this method carries 2 additional advantages: first, this technique can be performed in the postoperative period under local anesthesia, with minimal discomfort for the patients; second, when performed during the abdominal operation it represents an alternative to Seldinger’s jejunostomy, which carries some risks of serious complications such as leakage, bleeding, or abscess formation.3,4
From the analysis of our results, the described method for delivering enteral nutrition in patients with small bowel ostomy proves easy to apply and clinically effective. Enteral nutrition can be started as soon as possible after operation through the efferent loop of the ostomy; the management of jejunostomy is simple and safe, with no discomfort for the patients.
REFERENCES
1. Shetty V, Teubner A, Morrison K, Scott NA. Proximal loop jejunostomy is a useful adjunct in the management of multiple intestinal suture lines in the septic abdomen. Br J Surg. 2006; 93:1247-1250.
2. Grant J. Vascular access for TPN: technique and complications. In: Grant JP, ed. Handbook of TPN. Philadelphia, PA: W. B. Saunders Co; 1991:124.
3. Eddy VA, Snell JE, Morris JA Jr. Analysis of complications and long-term outcome of trauma patients with needle catheter jejunostomy. Am Surg. 1996;62:40-44.
4. Sonawane RN, Thombare MM, Kumar A, et al. Technical complications of feeding jejunostomy: a critical analysis. Trop Gastroenterol. 1997;18:127-128.
Fabio Pacelli, MD; Fabio Rotondi, MD; Fausto Rosa, MD; Maurizio Bossola, MD; Valerio Papa, MD; Antonio Pio Tortorelli, MD; Liliana Sollazzi, MD; and Giovanni Battista Doglietto, MD
From the Department of Surgical Sciences, Digestive Surgery Unit, Catholic University, School of Medicine, Rome, Italy
Received for publication March 5, 2007.
Accepted for publication July 2, 2007.
Correspondence: Fabio Pacelli, MD, Digestive Surgery Unit, Istituto di Clinica Chirurgica, Catholic University, School of Medicine, Largo A. Gemelli, 8, 00168 Rome, Italy. Electronic mail may be sent to fpacelli@rm.unicatt.it.
Copyright American Society for Parenteral and Enteral Nutrition Jan/ Feb 2008
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