Exploring the Techniques Used in Jejunostomy Feeding

The first successful feeding jejunostomy was performed in 1858. Today, this procedure is vital for providing long-term nutritional support to patients with conditions that prevent oral or gastric intake, employing several advanced and precise techniques used in jejunostomy feeding.

Quick Summary

A jejunostomy is a surgical procedure for long-term enteral feeding into the small intestine. Various placement techniques exist, each with unique approaches, advantages, and risks to consider based on patient needs.

Key Points

• Surgical Techniques: Jejunostomy tubes can be placed using open surgery, laparoscopic surgery, percutaneous endoscopy, or a needle catheter technique.

• Minimally Invasive Preference: Minimally invasive approaches like laparoscopy and PEJ are generally preferred over open surgery due to shorter recovery times and reduced complications.

• Witzel Tunnel: The Witzel technique, which creates a serosal tunnel around the tube, is often used to minimize the risk of fluid leakage at the insertion site.

• Technique Selection: The choice of technique is highly dependent on individual patient needs, comorbidities, and the surgeon's expertise.

• Long-Term vs. Short-Term: Nasojejunal tubes are for short-term use, while surgically placed jejunostomy tubes are intended for long-term nutritional support.

• Common Complications: Potential complications include tube dislodgement, blockage, leakage, and infection, regardless of the insertion technique.

Jejunostomy feeding, or J-tube feeding, is a method of delivering nutrition directly into the jejunum, a part of the small intestine. This procedure is necessary for patients with impaired swallowing, delayed stomach emptying, or obstructions in the upper gastrointestinal tract. The selection of a specific technique depends on the patient's overall health, the underlying condition, and the surgeon's expertise.

The Open Surgical Technique

The open surgical jejunostomy involves a traditional laparotomy, or open abdominal surgery, to access the jejunum. It is often performed in conjunction with other major gastrointestinal surgeries. This method offers surgeons clear visualization and direct control, which can be advantageous in complex cases.

Steps in the Open Surgical Procedure

• Midline Incision: A short midline incision is made to access the abdominal cavity.
• Jejunum Identification: The ligament of Treitz is identified, and a section of the proximal jejunum is brought to the incision site.
• Tube Placement: A purse-string suture is used to secure the feeding tube within the jejunal wall.
• Witzel Tunnel Creation: A serosal tunnel, known as a Witzel tunnel, is created to bury the tube within the jejunal wall, minimizing the risk of leaks.
• Abdominal Wall Fixation: The jejunum is then tacked to the interior of the abdominal wall to prevent torsion or obstruction.

The Laparoscopic Technique

As a minimally invasive option, laparoscopic jejunostomy uses several small incisions instead of one large one. A laparoscope, a thin tube with a camera, allows the surgeon to view the internal organs on a monitor. This method generally leads to reduced pain, fewer complications, and a shorter hospital stay compared to open surgery.

Laparoscopic Placement Process

• Port Placement: The surgeon creates small ports in the abdomen for the camera and surgical instruments.
• Jejunum Visualization: The jejunum is located and a site is chosen for tube insertion.
• Anchoring Sutures: The jejunum is anchored to the abdominal wall with sutures to ensure proper alignment and prevent twisting.
• Tube Insertion: A percutaneous needle and guidewire are used to help insert the feeding tube into the jejunum.
• Fixation: The tube is secured, the balloon is inflated, and the small incisions are closed. Some modern methods may use barbed sutures for quicker fixation.

Percutaneous Endoscopic Jejunostomy (PEJ)

This technique involves using an endoscope, a long flexible tube with a light and camera, to guide the placement of the feeding tube. A PEJ can be performed directly through the abdominal wall or, more commonly, a jejunal extension tube is passed through an existing percutaneous endoscopic gastrostomy (PEG) tube. The latter method is known as a transgastric jejunostomy (PEG-J).

How a PEJ is Performed

• Endoscopic Guidance: The endoscope is advanced to the jejunum to identify the ideal insertion site.
• Transillumination: The endoscope's light shines through the abdominal wall, confirming the correct location.
• Guidewire and Dilators: A trocar and guidewire are inserted into the jejunum, and dilators are used to enlarge the tract for the tube.
• Tube Securing: The jejunostomy tube is pulled into place and secured.

The Needle Catheter Technique

Often performed as an adjunct procedure during other major gastrointestinal resections, the needle catheter technique involves creating a submucosal tunnel. A fine-bore catheter is inserted into the jejunum and advanced distally.

Needle Catheter Procedure Details

• Submucosal Tunnel: A 4-5 cm submucosal tunnel is created, which helps prevent leakage.
• Catheter Insertion: The catheter is introduced through a needle and advanced into the jejunum.
• Suture Fixation: A purse-string suture is used to secure the catheter to the jejunal wall, and the jejunum is attached to the abdominal wall lining.

Comparison of Jejunostomy Techniques

Feature	Open Surgical	Laparoscopic	Percutaneous Endoscopic (PEJ)	Needle Catheter
Invasiveness	High (large incision)	Low (small incisions)	Low (endoscopic guided)	Low (fine catheter)
Visualization	Excellent (direct access)	Excellent (camera view)	Good (endoscopic view)	Limited (relies on needle)
Procedure Time	Shorter than laparoscopy for experienced surgeons	Varies, can be longer initially	Variable, depends on approach	Quick (often an adjunct)
Recovery	Longer hospital stay	Shorter hospital stay	Minimally invasive, relatively fast	Fast recovery post-procedure
Main Advantage	Optimal for complex cases	Less pain, shorter recovery	Avoids extensive surgery	Quick placement, good for adjunct procedures
Main Risk	Infection, adhesions, prolonged recovery	Bowel torsion, anesthesia risks	Tube migration, dysfunction	Catheter blockage, leakage

Which Technique Is Best?

The choice of technique is highly individualized. Minimally invasive methods, such as laparoscopic jejunostomy and percutaneous endoscopic jejunostomy, are increasingly becoming the standard of care due to improved patient outcomes and reduced recovery times. The open surgical approach is reserved for more complex cases or when performed alongside other major surgeries. The needle catheter method is often an ancillary procedure. Factors like the patient's existing anatomy, prior surgeries, and overall health status are critical in determining the most appropriate and safest approach for long-term enteral nutrition.

For more detailed information on jejunostomy tube management and care, refer to resources from reputable medical institutions and organizations, such as the National Institutes of Health (NIH).

Conclusion

Jejunostomy feeding is a crucial method for providing enteral nutrition when other routes are not viable. The techniques used in jejunostomy feeding have evolved significantly, from the traditional open surgery to modern, minimally invasive procedures. Open surgical, laparoscopic, percutaneous endoscopic, and needle catheter techniques each have specific applications, advantages, and risks. Advances in laparoscopic and endoscopic methods have made these less invasive approaches the preferred choice for many patients, leading to better recovery and fewer complications. Selecting the right technique requires a careful assessment by a healthcare team to ensure the best possible nutritional outcomes and quality of life for the patient.

Frequently Asked Questions

What is a jejunostomy feeding tube?

A jejunostomy feeding tube, or J-tube, is a medical device placed through the skin of the abdomen directly into the jejunum (the mid-section of the small intestine) to provide long-term nutrition, fluids, and medication.

When is jejunostomy feeding necessary?

Jejunostomy feeding is necessary when a person cannot eat or drink safely, has problems with stomach emptying (gastroparesis), an obstruction in the stomach, or requires nutritional support after major upper gastrointestinal surgery.

How is J-tube feeding administered?

J-tube feeding is typically administered via a feeding pump at a continuous, slow drip rate over a specific period, often many hours. This slow rate is needed because the jejunum processes food differently than the stomach.

What are the common complications of jejunostomy feeding?

Common complications can include tube displacement or blockage, leakage at the insertion site, infection, bowel obstruction, and gastrointestinal issues like diarrhea and abdominal distention.

How should the jejunostomy site be cared for?

The stoma site must be cleaned and dried daily to prevent skin irritation and infection. Your healthcare team will provide specific instructions, but general care involves washing with warm soapy water and securing the tube to prevent movement and leakage.

What should I do if the J-tube falls out?

If an established jejunostomy tube falls out, it must be reinserted as soon as possible to prevent the stoma from closing. It is critical to contact a healthcare provider immediately, as a tract can close within hours.

How often should a J-tube be flushed?

A J-tube should be flushed with warm, sterile water before and after every feed or medication administration. During continuous feeding, flushing is often recommended every 4 to 6 hours to prevent clogging.