Laparoscopic percutaneous jejunostomy for long term enteral access

Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!

Purpose

Feeding jejunostomy (FJ) is a critical procedure to establish a source of enteral nutrition for upper gastrointestinal disorders. Minimally invasive surgery has the inherent benefit of better patient outcomes, less postoperative pain, and early discharge. This study aims to describe our total laparoscopic technique of Witzel FJ and to compare its outcome with its open counterpart.

Methods

A retrospective database analysis was performed in patients who underwent laparoscopic (n = 20) and open (n = 21) FJ as a stand-alone procedure from July 2018 to July 2022. A readily available nasogastric tube (Ryles tube) and routine laparoscopic instruments were used to perform laparoscopic FJ. Perioperative data and postoperative outcomes were analyzed.

Results

Baseline preoperative variables were comparable in both groups. The median operative duration in the laparoscopic FJ group was 180 minutes vs. 60 minutes in the open FJ group (p = 0.01). Postoperative length of hospital stay was 3 days vs. 4 days in the laparoscopic and open FJ groups, respectively (p = 0.08). Four patients in the open FJ group suffered from an immediate postoperative complication (none in the laparoscopic FJ group). After a median follow-up of 10 months, fewer patients in the laparoscopic FJ group had complications such as tube clogging, tube dislodgement, surgical-site infection, and small bowel obstruction.

Conclusion

Laparoscopic FJ with the Witzel technique is a safe and feasible procedure with a comparable outcome to the open technique. Patient selection is vital to overcome the initial learning curve.

Laparoscopic jejunostomy for enteral nutrition in gastric cancer patients: A report of two cases: A case report

INTRODUCTION AND IMPORTANCE

Jejunostomy is often indicated for patients with oral intake difficulties and unresectable gastric cancer, patients at risk of postoperative complications, and patients who require nutritional management after gastrectomy. In this report, we discuss the cases with laparoscopic jejunostomy in our department.

CASE PRESENTATION

Case 1: An upper gastrointestinal endoscopy performed for close examination in a 60-year-old male revealed upper gastric cancer with extensive invasion and lower esophageal stenosis. He had difficulty with esophageal transit and, consequently, underwent a laparoscopic jejunostomy and staging laparoscopy. Case 2: Upper gastrointestinal endoscopy in a 62-year-old male revealed type 3 tumor in the gastric antrum. He had a history of chronic obstructive pulmonary disease requiring home oxygen therapy, pulmonary hypertension, and heart failure, and was at a high perioperative risk. Consequently, both laparoscopic distal gastrectomy and laparoscopic jejunostomy were performed.

CLINICAL DISCUSSION

Enteral nutrition has many advantages over venous nutrition, including maintenance of immunity and intestinal mucosa, avoidance of bacterial translocation, and decreased risk of catheter infection. Although there are a few reports of cases with laparoscopic jejunostomy, it is expected that the technique will become more widespread and safe in the future.

CONCLUSION

Laparoscopic jejunostomy is considered a useful, minimally invasive, and safe technique.

Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Jejunostomy Tube Insertion for Enteral Nutrition: Comparison of Outcomes after Laparoscopic versus Radiologic Insertion

PURPOSE

To retrospectively compare technical success and major complication rates of laparoscopically versus radiologically inserted jejunostomy tubes.

MATERIALS AND METHODS

In this single-institution retrospective study, 115 patients (60 men; mean age, 59.7 y) underwent attempted laparoscopic jejunostomy tube insertion as a standalone procedure during a 10-year period and 106 patients (64 men; mean age, 61.0 y) underwent attempted direct percutaneous radiologic jejunostomy tube insertion during an overlapping 6-year period. Clinical outcomes were retrospectively reviewed with primary focus on predictors of procedure-related major complications within 30 days.

RESULTS

Patients undergoing laparoscopic jejunostomy tube insertion were less likely to have previous major abdominal surgery (P < .001) or to be critically ill (P < .001) and had a higher body mass index (P = .001) than patients undergoing radiologic insertion. Technical success rates were 95% (110 of 115) for laparoscopic and 97% (103 of 106) for radiologic jejunostomy tube insertion (P = .72). Major procedural complications occurred in 7 patients (6%) in the laparoscopic group and in 5 (5%) in the radiologic group (P = 1.0). For laparoscopic jejunostomy tubes, only previous major abdominal surgery was significantly associated with a higher major procedure complication rate (14% [5 of 37] vs 3% [2 of 78] in those without; P = .039). In the radiologic jejunostomy group, only obesity was significantly associated with a higher major complication rate: 20% (2 of 10) vs 3% (3 of 96) in nonobese patients (P = .038).

CONCLUSIONS

Laparoscopic and radiologic jejunostomy tube insertion both showed high success and low complication rates. Previous major abdominal surgery and obesity may be pertinent discriminators for patient selection.

Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes

Background

In recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes.

Methods

The medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes.

Results

Fifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days.

Conclusions

Laparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success.

Laparoscopic percutaneous jejunostomy with intracorporeal V-Loc jejunopexy in esophageal cancer

BACKGROUND

Barbed sutures are widely used in various laparoscopic digestive surgeries. The purpose of this paper is to present our initial experience of laparoscopic percutaneous jejunostomy with unidirectional barbed sutures in esophageal cancer patients and compare it with our early cases using traditional transabdominal sutures.

METHODS

A total of 118 esophageal cancer patients who underwent laparoscopic percutaneous jejunostomy were identified in a single institution in Taiwan from June 2014 to May 2016. The authors' traditional technique consisted of using transabdominal sutures with bolsters to fix a jejunum loop onto the anterior abdominal wall. A novel technique was introduced using intracorporeal suturing with knotless unidirectional barbed monofilament absorbable sutures (V-Loc) to attain a seal around the feeding catheter. A comparison between these two techniques was performed.

RESULTS

Twenty cases with barbed V-Loc sutures and 98 cases with transabdominal sutures were identified. The V-Loc sutures appeared to reduce peristomal skin ulcers (19.4 vs. 0 %, p = 0.040), postoperative pain scores during the first 24 h (1.8 ± 1.4 vs. 0.9 ± 1.1, p = 0.007) and on postoperative day 2 (1.7 ± 1.4 vs. 1.0 ± 0.8, p = 0.026) when compared to patients receiving transabdominal sutures. The mean suturing time using V-Loc sutures was 22 min (14-60 min). The mean onset to resumption of enteral feeding was 1.8 ± 0.8 days and the mean duration of postoperative hospital stay was 8 ± 5.1 days, both of which were comparable in the two groups. There was no surgical mortality in our series.

CONCLUSIONS

In the study cohort, the use of knotless unidirectional barbed sutures instead of traditional transabdominal sutures had similar outcomes and appears to be a feasible option for intracorporeal jejunopexy when performing laparoscopic jejunostomy in patients with esophageal cancer.

Outcomes of laparoscopic feeding jejunostomy tube placement in 299 patients

BACKGROUND

Jejunostomy catheters for jejunal feeding are an effective method to improve nutritional status in malnourish patients. However, this procedure is commonly being performed using an open approach, which can be associated with more postoperative pain and prolonged recovery. The objective of this study was to assess the outcomes of patients who underwent placement of feeding jejunostomy using a laparoscopic approach.

METHODS

A retrospective review was performed of patients who underwent laparoscopic jejunostomy tube placement between 1998 and 2014. Main outcome measures included indication for catheter placement, rate of conversion rate to open surgery, perioperative and late morbidity and in-hospital mortality.

RESULTS

Two hundred and ninety-nine consecutive patients underwent laparoscopic jejunostomy during the study period. The mean age was 64 years, and 81% of patients were male. The mean BMI was 26.2 kg/m(2). The most common indications for catheter placement were resectable esophageal cancer (78%), unresectable esophageal cancer (10%) and gastric cancer (6%). There were no conversions to open surgery. The 30-day complication rate was 4.0% and included catheter dislodgement (1%), intraperitoneal catheter displacement (0.7%), catheter blockage (1%) or breakage (0.3%), site infection requiring catheter removal (0.7%) and abdominal wall hematoma (0.3%). The late complication rate was 8.7% and included jejuno-cutaneous fistula (3.7%), jejunostomy tube dislodgement (3.3%), broken or clogged J-tube (1.3%) and small bowel obstruction (0.3%). The 30-day mortality was 0.3% for a patient with stage IV esophageal cancer who died in the postoperative period secondary to respiratory failure.

CONCLUSION

In this large consecutive series of feeding jejunostomy, the laparoscopic approach is feasible and safe and associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.

Gastroparesis: a review of current and emerging treatment options

Gastroparesis is a motility disorder of the stomach causing delay in food emptying from the stomach without any evidence of mechanical obstruction. The majority of cases are idiopathic. Patients need to be diagnosed properly by formal testing, and the evaluation of the severity of the gastroparesis may assist in guiding therapy. Initially, dietary modifications are encouraged, which include frequent and small semisolid-based meals. Promotility medications, like erythromycin, and antiemetics, like prochlorperazine, are offered for symptom relief. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, can be considered. Hemin therapy and gastric electric stimulation are emerging treatment options that are still at different stages of research. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

Factors influencing admission and outcomes in gastroparesis

BACKGROUND

Current data suggest that gastroparesis is associated with an increased mortality, with reported rates ranging from 4% to nearly 40%. Considering this variability, the goal of this study was to determine mortality rates and risk factors for adverse outcomes in gastroparesis.

METHODS

Using the diagnosis code for gastroparesis, admission rates, duration of hospitalizations, discharge status, and inpatient mortality were determined for emergency department encounters and admissions compiled in the Nationwide Emergency Department Sample and Nationwide Inpatient Sample of the Agency for Healthcare Research and Quality. Comorbid conditions, procedural evaluations, age cohort, and gender distribution were examined as potential risk factors.

KEY RESULTS

More than 50% of the emergency encounters for gastroparesis resulted in admission with age, cardiovascular, renal, and infectious disorders, but not diabetes mellitus being associated with higher admission rates. Inpatient mortality was 1.2 ± 0.1%, was not negatively affected by diabetes mellitus as comorbidity, and increased with coexisting infections and with more aggressive therapy. Discharge status was similarly affected by comorbidities, treatment complications, and more aggressive therapy.

CONCLUSIONS & INFERENCES

These results demonstrate that gastroparesis does not come with a high mortality risk, with most deaths being due to comorbid conditions. Although gastrostomies and/or nutritional support were used in only a minority of admissions, the associated increase in morbidity and mortality highlights the need to carefully select the right candidates for such interventions and to discuss the common occurrence of adverse outcomes with patients.

Trocar guided laparoscopic feeding jejunostomy: a simple new technique

PURPOSE

Several techniques of laparoscopic feeding jejunostomy have been described. Most of them require costly commercial kits. Here we present a novel, simple, low-cost method for laparoscopic jejunostomy tube placement.

METHODS

This technique involves 4 ports. A left lateral "guide" trocar is used as a landmark for tube placement. A jejunal loop is selected and 4 vicryl sutures are placed in a diamond shape on the antimesenteric side of the intestine and left untied. These 4 stitches are extracted using a transabdominal suture grasper inserted through 4 small incisions around the left lateral guide trocar. After an enterotomy is made in the center of these 4 stitches using cautery device, the left lateral trocar is removed and a 12 Fr Foley catheter is inserted in the trocar site and introduced into the bowel. The 4 stitches are pulled toward the abdominal wall and gently tied without additional suturing. Eight patients who underwent this procedure between 2007 and 2009 were reviewed.

RESULTS

The procedure was successful in all patients. The median operative time was 70.5 minutes. There were no postoperative complications with respect to infection, bleeding, or bowel obstruction, and no perioperative mortality.

CONCLUSIONS

Our trocar-guided approach for laparoscopic feeding jejunostomy placement is a simple, cost-effective, safe, and effective method.

Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications

BACKGROUND

Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients.

OBJECTIVE

To review the current techniques of gastrointestinal tract access for EN.

METHODS

For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: "enteral nutrition," "critically ill," and "gut access." We excluded outdated abstracts.

RESULTS

For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially.

CONCLUSION

In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.

Totally laparoscopic feeding jejunostomy - a technique modification

In oncological patients with upper gastrointestinal tract tumours, dysphagia and cachexy necessitate gastrostomy or jejunostomy as the only options of enteral access for long-term feeding. In this article the authors describe a modified technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy. A 48-year-old male patient with gastroesophageal junction tumour and a 68-year-old male patient with oesophageal tumour were operated on using the described technique. Exploratory laparoscopy was performed. Then the feeding jejunostomy was made using a Cystofix^® TUR catheter. The jejunum was fixed to the abdominal wall with four 2.0 Novafil™ transabdominal stitches. Two additional sutures were placed caudally about 4 cm and 8 cm from the jejunostomy, aiming at prevention of jejunal torsion. Total operating time was 45 min. There was no blood loss. There were no intraoperative complications. The only adverse event was one jejunostomy wound infection that responded well to oral antibiotics. There were no mortalities. The described technique has most of the benefits of laparoscopic feeding jejunostomy with some steps added from the open operation making the procedure easier to perform as part of a staging operation with a relatively short additional operating time. The proposed transabdominal stitches make the technique easier to apply. Two additional ‘anti-torsion sutures’ prevent postoperative volvulus. Use of the Cystofix catheter allows easy introduction of the catheter into the peritoneal cavity and the jejunal lumen, providing a good seal at the same time. Further studies on larger groups of patients are required to assess long-term outcomes of the proposed modified technique.

Advances in the management of gastroparesis

The treatment goals for patients with gastroparesis are to control symptoms; to correct fluid, electrolyte, and nutritional deficiencies; and to identify and treat the underlying cause of gastroparesis. For mild symptoms, dietary modifications and a low-dose antiemetic and/or prokinetic agent might provide satisfactory control of symptoms. Dietary treatments include decreasing the solid food component while increasing the liquid nutrient component of meals. Fat and fiber intake should be minimized. Metoclopramide, despite its potential for neurological side effects, remains a prokinetic treatment for symptomatic patients. In patients with diabetic gastroparesis, careful regulation of glycemic control may help to reduce symptoms. Medical management of patients with gastroparesis who do not respond to initial antiemetic or prokinetic therapy or who develop medication-related side effects involves the use of other prokinetic and antiemetic agents with different mechanisms of action. Combinations of prokinetic and antiemetic agents often are tried in patients with persistent symptoms. In some patients with persistent refractory symptoms and failure to maintain adequate fluid and/or nutritional intake, bypassing the stomach with jejunostomy feedings may be necessary. Gastric electrical stimulation is a treatment for refractory gastroparesis. Based on initial studies showing symptom benefit, especially in patients with diabetic gastroparesis, gastric electrical stimulation was granted humanitarian US Food and Drug Administration approval for the treatment of chronic, refractory nausea and vomiting secondary to idiopathic or diabetic gastroparesis. However, which patients are likely to respond, the optimal electrode position, and the optimal stimulation parameters remain areas that need to be addressed.

Gastroparesis: approach, diagnostic evaluation, and management

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

Laparoscopic feeding jejunostomy in esophagogastric cancer

BACKGROUND

Patients with esophagogastric malignancies often require nutritional supplementation in the perioperative period, especially in the setting where neoadjuvant therapy may delay tumor resection. A simple technique is described here that can be performed at the time of staging laparoscopy and that has not been described before.

RESULTS

Forty-three patients treated over a 4-year period who had a laparoscopic feeding jejunostomy placed at the time of staging laparoscopy were reviewed. Of these, 35 had preoperative chemotherapy according to a modified MRC OEO2 protocol. In the period between staging and eventual resection, 32% required immediate feeding, and in 14% of those who were thought not to need feeding it later became necessary. More patients gained weight or had a rise in albumin in the group that had jejunal feeding (p < 0.05). The mean time to surgery was 10 weeks. There were no conversions to an open procedure, nor were there any laparotomies for tube-related complications. Dislodgement was recorded in 6 patients; blockage, in 4. In most of these cases a simple bedside replacement of the tube was all that was required. Mean time in the operating room for each procedure was 44 minutes.

CONCLUSIONS

Laparoscopic percutaneous feeding jejunostomy is a safe and simple technique that adds little to the morbidity and cost of managing patients with esophagogastric cancers. It facilitates optimization of nutrition in the perioperative period for these patients, especially in those receiving preoperative chemotherapy.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Delayed gastric emptying: Whom to test, how to test, and what to do

Gastroparesis, or delayed gastric emptying, is a common cause of chronic nausea and vomiting as seen in a gastroenterology practice. Diabetic, postsurgical, and idiopathic causes remain the three most common forms of gastroparesis. In addition to nausea and vomiting, symptoms of gastroparesis may include early satiety, postprandial fullness, and abdominal pain. Physiologic changes that may explain symptoms in patients with gastroparesis, in addition to delayed gastric emptying, include impaired fundic accommodation, antral hypomotility, gastric dysrhythmias, pylorospasm, and perhaps visceral hypersensitivity. Diagnosis of gastroparesis is best determined using a radioisotope-labeled solid meal with scintigraphic imaging for at least 2 hours, and preferably 4 hours, postprandially. Most commonly, a 99mTc sulfur colloid-labeled egg sandwich with imaging at 0, 1, 2, and 4 hours is used. Extension of the gastric emptying test to 4 hours improves the accuracy of the test, but unfortunately, this is not commonly performed at many centers. Emptying of liquids remains normal until the late stages of gastroparesis and is less useful. The aims of treatment should be to control symptoms and maintain adequate nutrition and hydration. Patients should be advised to eat small meals and to limit their intake of fat and fiber. Additional dietary recommendations may include increasing caloric intake in the form of liquids. For diabetic patients, control of blood glucose levels is important, as symptom exacerbation is frequently associated with poor glycemic control. Specific treatment often begins with metoclopramide, 10 mg, up to four times daily, after a discussion of possible side effects with the patient. An antiemetic agent, such as prochlorperazine, 5 to 10 mg orally or 25 mg by suppository, can be added on an as-needed basis every 4 to 6 hours to control nausea. If these antiemetic medications are not effective, or if side effects develop, orally dissolving ondansetron, 8 mg every 8 to 12 hours, can be tried on an as-needed basis. If this regimen is unsuccessful, then alternative prokinetic agents--erythromycin, 125 mg, or tegaserod, 6 mg, prior to meals--can be tried. For cases refractory to these treatments, referral to a center with US Food and Drug Administration permission to use domperidone should be considered. Alternatively, symptom modulators such as low-dose tricyclic antidepressants can be tried to reduce symptoms, but these do not improve gastric emptying. In patients for whom all medical therapy fails, other options that are tried at experienced centers include the injection of botulinum toxin into the pylorus, placement of a feeding jejunostomy, and/or placement of a gastric electrical stimulator.

Nutrition and motility disorders

The purpose of this article is to give an overview of the relation between feeding and gastrointestinal symptoms and complaints, and to review different motility disorders that have implications for food intake. We also report the consequences for nutrition state and the evidence-based principles of dietary modification in patients with motility disorders.

Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts

BACKGROUND

Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ.

OBJECTIVE

To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution.

METHODS

Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed.

RESULTS

Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14).

CONCLUSIONS

DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.

Laparoscopic Feeding Jejunostomy Technique as Part of Staging Laparoscopy

Placement of a feeding jejunostomy tube is indicated for patients who need enteral access but where a gastrostomy is not feasible. This paper presents the technique and results of laparoscopic placement of feeding jejunostomy tubes in patients presenting with esophagogastric cancer. From December 2002 to February 2004, patients diagnosed with esophagogastric cancer with a potentially resectable lesion underwent staging laparoscopy. Laparoscopic feeding jejunostomy was performed on patients who were potential candidates for chemotherapy with palliative intent or neoadjuvant treatment prior to resection surgery. Surgical technique, recovery of bowel function, commencement of feeding jejunostomy, total time tube was in situ, and perioperative complications were analyzed. Of the 22 patients who underwent staging laparoscopy, a feeding jejunostomy tube was placed in 18. The remaining 4 patients were deemed to have advanced disease precluding any therapeutic options and underwent placement of esophageal stents. Feeding tubes remained in situ for a median time period of 76 days. Fourteen patients required enteral support and tubes were used for a median of 30 days. Complications from tube placement included 2 cases of wound infections, 1 of minor leak and 1 tube dislodgment. Patients were followed up for a median time of 112 days. Findings from current series suggest that placement of a feeding jejunostomy tube at the time of staging laparoscopy is a safe and reliable means of providing and maintaining nutrition for patients presenting with esophagogastric cancers.

Laparoscopic feeding jejunostomy: a systematic review

BACKGROUND

Enteral feeding devices have gained popularity since the beneficial effects of enteral nutrition have been clarified. Laparoscopic placement of a feeding jejunostomy is the most recently described enteric access route. In order to classify current surgical techniques and assess evidence on safety of laparoscopic feeding jejunostomy, a systematic review was performed.

METHODS

The electronic databases Medline, Cochrane, and Embase were searched. Reference lists were checked and requests for additional or unpublished data were sent to authors. Outcome measures were surgical technique and catheter-related complications.

RESULTS

Enteral access for feeding purposes can be effectively achieved by laparoscopic jejunostomy. Laparoscopic jejunostomy can be accomplished by either total laparoscopic or laparoscopic-aided techniques. The most experience was obtained with total laparoscopic placement. Which technique to apply should depend on the surgeon's expertise. Conversion rate is similar to other laparoscopic procedures. Complications can be serious and therefore strict patient selection should be warranted.

CONCLUSION

Laparoscopic feeding jejunostomy is a viable method to obtain enteral access with the advantages of minimally invasive surgery.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs

OBJECTIVE

To evaluate feasibility of performing laparoscopic-assisted placement of a jejunostomy feeding tube (J-tube) and compare complications associated with placement, short-term feedings, and medium-term healing with surgically placed tubes in dogs.

DESIGN

Prospective study.

ANIMALS

15 healthy mixed-breed dogs.

PROCEDURES

Dogs were randomly allocated to undergo open surgical or laparoscopic-assisted J-tube placement. Required nutrients were administered by a combination of enteric and oral feeding while monitoring for complications. Radiographic contrast studies documented tube direction and location, altered motility, or evidence of stricture.

RESULTS

Jejunostomy tubes were successfully placed in the correct location and direction in all dogs. In the laparoscopic group, the ileum was initially selected in 2 dogs, 2 dogs developed moderate hemorrhage at a portal site, and 2 J-tubes kinked during placement but were successfully readjusted postoperatively. All dogs tolerated postoperative feedings. All dogs developed minor ostomy site inflammation, and 1 dog developed bile-induced dermatitis at the ostomy site. Despite mild, transient neutrophilia, no significant difference was noted in WBC counts between groups. No dog had altered gastric motility or evidence of stricture, although the jejunopexy site remained identifiable in several dogs at 30 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Requirements for successful J-tube placement were met by use of a laparoscopic-assisted technique, and postoperative complications were mild and comparable to those seen with surgical placement. Laparoscopic-assisted J-tube placement compares favorably to surgical placement in healthy dogs and should be considered as an option for dogs requiring enterostomy feeding but not requiring a celiotomy for other reasons.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results

BACKGROUND

We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access.

METHODS

In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60-80 ml/h was reached on the 3rd or 4th postoperative day.

RESULTS

In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions.

CONCLUSIONS

Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

A systematic review of surgical therapy for gastroparesis

Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis might result in recurrent hospitalizations, malnutrition, and significant mortality. Patients failing medical therapy are often considered for a variety of surgical interventions, the efficacy of which is not well studied. This review summarizes available literature on surgical interventions in gastroparesis. A MEDLINE search for the period from 1966 to 2002 was performed to identify all English language literature regarding surgical interventions in gastroparesis. Therapies reviewed were gastrostomy, jejunostomy, gastric pacing/stimulation, and gastrectomy or surgical drainage procedures. Candidate studies involved human subjects and included surgical series or trials. The search was conducted independently by two authors and discrepancies resolved by consensus opinion. Seventeen articles met inclusion criteria. These included series reporting on gastrostomy (2), jejunostomy (3), gastric stimulation (2), and gastrectomy for postsurgical (6), diabetic (3), and idiopathic (1) gastroparesis. All trials were unblinded, uncontrolled case series or retrospective reviews. Methodologic differences did not allow for pooled analysis. Completion gastrectomy seems to provide symptom relief in postsurgical gastroparesis. Benefits of gastric surgery for other forms of gastroparesis are not adequately studied. Gastrostomy might provide symptom improvement, but only 26 subjects in two trials were evaluable. Jejunostomy improved symptoms and nutrition in 32 evaluable subjects in three trials but had significant complications. Gastric neurostimulation improves symptoms of nausea and vomiting, but therapeutic gain beyond placebo has not been demonstrated. Limited data exist concerning surgical therapies of gastroparesis. Completion gastrectomy seems effective for postsurgical gastroparesis, but a cautious approach is warranted before surgical therapies in diabetic or idiopathic gastroparesis are used.

Acute Intestinal Pseudo-obstruction

Acute pseudo-obstruction may manifest clinically in one of three forms--acute gastroparesis, ileus, and acute colonic pseudo-obstruction (Ogilvie's syndrome). Though formerly associated primarily with the postoperative state, these entities are increasingly recognized in association with a wide variety of major medical problems. There are few controlled studies to guide the clinician in the management of these disorders. Treatment remains largely empirical, and time-honored, based primarily on "bowel rest," nasogastric decompression, and supportive care. While a wide variety of pharmacologic approaches have been advocated, few have been subjected to, or survived, the rigors of a properly controlled trial. Neostigmine is a notable exception, and has been shown to be effective in Ogilvie's syndrome. Perforation is a significant threat in megacolon; colonoscopic, or surgical decompression may, therefore, be indicated. Both are associated with significant risks in this context, but may prevent progression to perforation with its attendant mortality. New approaches seek to exploit current concepts in the pathophysiology of ileus and megacolon but have not, as yet, achieved efficacy in human studies.

Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis

Patients with gastroparesis frequently present challenging clinical, diagnostic, and therapeutic problems. Data from 146 gastroparesis patients seen over six years were analyzed. Patients were evaluated at the time of initial diagnosis and at the most recent follow-up in terms of gastric emptying and gastrointestinal symptomatology. The psychological status and physical and sexual abuse history in female idiopathic gastroparesis patients were ascertained and an association between those factors and gastrointestinal symptomatology was sought. Eighty-two percent of patients were females (mean age: 45 years old). The mean age for onset of gastroparesis was 33.7 years. The etiologies in 146 patients are: 36% idiopathic, 29% diabetic, 13% postgastric surgery, 7.5% Parkinson's disease, 4.8% collagen vascular disorders, 4.1% intestinal pseudoobstruction, and 6% miscellaneous causes. Subgroups were identified within the idiopathic group: 12 patients (23%) had a presentation consistent with a viral etiology, 48% had very prominent abdominal pain. Other subgroups were gastroesophageal reflux disease and nonulcer dyspepsia (19%), depression (23%), and onset of symptoms immediately after cholecystectomy (8%). Sixty-two percent of women with idiopathic gastroparesis reported a history of physical or sexual abuse, and physical abuse was significantly associated with abdominal pain, somatization, depression, and lifetime surgeries. At the end of the follow-up period, 74% required continuous prokinetic therapy, 22% were able to stop prokinetics, 5% had undergone gastrectomy, 6.2% went onto gastric electrical stimulation (pacing), and 7% had died. At some point 21% had required nutrition support with a feeding jejunostomy tube or periods of parenteral nutrition. A good response to pharmacological agents can be expected in the viral and dyspeptic subgroups of idiopathics, Parkinson's disease, and the majority of diabetics, whereas a poorer outcome to prokinetics can be expected in postgastrectomy patients, those with connective tissue disease, a subgroup of diabetics, and the subset of idiopathic gastroparesis dominated by abdominal pain and history of physical and sexual abuse. Appreciation of the different etiologies and psychological status of the patients may help predict response to prokinetic therapy.

Gastric pacing improves emptying and symptoms in patients with gastroparesis

BACKGROUND & AIMS

No effective treatment is available for patients with gastroparesis refractory to standard medical therapy. The aim of this study was to investigate the effects of gastric pacing on gastric electrical activity, gastric emptying, and symptoms in patients with gastroparesis.

METHODS

Nine patients with gastroparesis participated in this study. Four pairs of cardiac pacing wires were implanted on the serosa of the stomach. The protocol consisted of two portions: a temporary inpatient study period and an outpatient study for a period of 1 month or more.

RESULTS

Gastric pacing entrained the gastric slow wave in all subjects and converted tachygastria in 2 patients into regular 3-cpm slow waves. Gastric emptying was significantly improved after the outpatient treatment with gastric pacing. The gastric retention at 2 hours was reduced from 77.0% +/- 3.3% to 56.6% +/- 8.6% (P < 0.05). Symptoms of gastroparesis were substantially reduced at the end of the outpatient treatment (1.51 +/- 0.46 vs. 2.84 +/- 0.61; P < 0.04). Eight of 9 patients no longer relied on jejunostomy tube feeding, and no adverse events were noted related to the pacing unit.

CONCLUSIONS

Gastric pacing seems to be able to improve symptoms of gastroparesis and to accelerate gastric emptying in patients with gastroparesis. More controlled studies are necessary to further investigate the role of gastric pacing in clinical practice.