Feeding jejunostomy for post-operative nutritional support

Pancreatic surgery: indications, complications, and implications for nutrition intervention

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature

Laparoscopic sleeve gastrectomy has recently become a feasible option in the management of morbid obesity. One of the most feared complications of this procedure is staple line disruption and leakage. There are, to our knowledge, few literature reports that try to explain the reasons and management of this rare but serious complication. We report a case of staple line disruption that was managed using a T-tube gastrostomy. A 50-year-old female, 2 weeks status post-sleeve gastrectomy in an outside facility, was admitted to the emergency room at Cleveland Clinic Florida with new onset of fever, abdominal pain, jaundice, hematemesis, and melena. A computed tomography scan of the abdomen revealed a large extravasation of contrast material parallel to the gastric sleeve. A diagnostic laparoscopy was performed that showed a distal and proximal disruption of the staple line. A T-tube gastrostomy with a large proximal and distal limb was placed into the most distal area of disruption. After thorough over sewing and drainage of the proximal site and T-tube, a feeding jejunostomy was placed. The T-tube permitted to control the leak and to have a controlled fistula. Four weeks postoperatively, the T-tube was removed after the patient had a negative Gastrografin study and tolerated oral fluids with a clamped T-tube. The long-term recovery and follow-up were uneventful. T-tube gastrostomy appears to be a safe and feasible treatment option for staple line disruption after vertical sleeve gastrectomy. Early detection and drainage remain the most important principles to manage this type of complication.

Enteral nutrition and the critically ill

Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.

A pitfall in the technique of jejunal tube insertion, resulting in jejunal perforation

Enteral feeding by a jejunostomy tube is a reliable and cost-effective method for both long- and short-term nutritional support in selected patients, although a high complication rate has been reported in some series. The authors report on jejunal perforation in an infant, caused by a kinked jejunostomy tube, and emphasize this possible pitfall as a warning to others.