Complications of surgical feeding jejunostomy in trauma patients

Safety of elective enteral access in elderly patients: a comparative analysis of perioperative risk

BACKGROUND

Elderly patients can experience torpid hospitalization that is often characterized by malnutrition. In this setting, enteral feeding may facilitate improvement in nutritional status. This study aimed to compare the perioperative outcomes between elderly (age of ≥65 years old) and nonelderly (age of <65 years old) patients undergoing elective enteral access placement.

METHODS

Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care facility were retrospectively reviewed. Differences in baseline characteristics between nonelderly and elderly patients were adjusted using entropy-balanced weights. Subsequently, multivariate logistic and linear regression models were developed to evaluate the association between elderly status and outcomes of interest.

RESULTS

Overall, 914 patients with enteral access met the inclusion criteria, of whom 471 (51.5%) were elderly. Elderly patients more commonly received percutaneous gastrostomy and had a higher burden of comorbidities as measured using the Charlson Comorbidity Index than nonelderly patients. Multivariate risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups. After adjustment, despite no significant association with inhospital mortality, reoperation, or time to feeding goals, elderly status was linked to an approximately 8-day reduction in length of stay (95% CI, -14.28 to -2.30; P = .007) and significantly lower odds of total parenteral nutrition (adjusted odds ratio [AOR], 0.59; 95% CI, 0.37-0.94; P = .026) and nonelective readmission (AOR, 0.65; 95% CI, 0.49-0.86; P = .003). In addition, elderly status was associated with significantly greater odds of nonhome discharge (AOR, 1.58; 95% CI, 1.17-2.13; P = .003).

CONCLUSION

Despite having more comorbidities than their nonelderly counterparts, elderly patients experienced favorable nutritional and perioperative outcomes after enteral access placement.

Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review

While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

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.

Nonocclusive mesenteric ischemia: A rare but lethal complication of enteral nutrition in critically ill patients

BACKGROUND

The American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism guidelines recognize that critically ill patients receiving stable, low doses of vasopressors have experienced the advantages of early initiation of enteral nutrition (EN). However, clinical questions remained unanswered including vasopressor combinations associated with complications, the advent of other therapies during hypotensive states, as well as the volume and content of EN that might contribute to the development of a nonocclusive mesenteric ischemia (NOMI).

PRESENTATION

A 68-year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease with two-vessel bypass grafting, and peripheral vascular disease underwent subtotal excision of an infected right axillofemoral-femoral bypass graft. Postoperatively, EN was held because of hemodynamic instability and postsurgical complications. A fiber-free, high-protein, and low-residue formula was started at 10 ml/h while the patient was receiving stable doses of midodrine, norepinephrine, and vasopressin. Despite advancement of tube-feed rates to goal, nasogastric output never exceeded 300 ml. Computerized tomography of the abdomen showed diffuse bowel distention with pneumatosis, concerning for bowel ischemia. No surgical interventions were pursued, and the patient died.

CONCLUSIONS

Our patient developed NOMI postoperatively while receiving EN. Further studies addressing EN route, trophic vs full EN, recommended formula, the safety of vasoactive agents, the addition of fiber to EN, and continuous venovenous hemodiafiltration in relation to NOMI are needed, as there continues to be clinical controversy regarding these topics.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Safety and Outcomes of Early Enteral Nutrition in Circulatory Shock

Circulatory shock is one of the most common reasons for an intensive care unit admission, has been shown to impair gut barrier and immune functions, and promotes dysbiosis. The exact timing and dose of enteral nutrition (EN) in circulatory shock remains unclear. In fact, because of fear of complications such as nonocclusive mesenteric ischemia and bowel necrosis and splanchnic steal phenomenon, clinicians may hesitate to start EN in critically ill patients with circulatory shock. In this narrative review, we identify and appraise contemporary evidence evaluating the safety and outcomes of EN in circulatory shock.

A selective placement strategy for surgical feeding tubes benefits trauma patients

BACKGROUND

The indications for surgical feeding tube (SFT) placement in trauma patients are poorly defined. Patient selection is critical as complications from SFTs have been reported in up to 70% of patients. A previous analysis by our group determined that 25% of the SFTs we placed were unnecessary and that older patients, patients with head and spinal cord injuries, and patients who needed a tracheostomy were more likely to require long-term SFTs. Following this study, we modified our institutional guidelines for SFT placement. We hypothesized that a more selective placement strategy would result in fewer unnecessary SFTs.

METHODS

A retrospective review of all adult patients from 2012 to 2016 with an intensive care unit length of stay longer than 4 days and an SFT placed during admission was conducted. This group was compared to data collected prior to our change in practice (2007-2010). Data from 2011 were excluded as a washout period. "Necessary" SFT use was defined per established guidelines as either daily use of the SFT through discharge or for 28 days or longer and "unnecessary" SFT use as all others.

RESULTS

Two hundred fifty-seven SFTs were placed from 2007 to 2010 and 244 from 2012 to 2016. Following implementation of our selective SFT placement strategy, unnecessary SFT placement decreased from 25% in 2007 to 2010 to 8% in 2012 to 2016 (p < 0.0001). Significant predictors of necessary SFT placement by univariate regression were as follows: increasing age (odds ratio [OR] 1.03/year; 95% confidence interval [CI], 1.01-1.04), head injury (OR, 2.80; 95% CI, 1.71-4.60), cervical spinal cord injury (OR, 4.42; 95% CI, 1.34-14.50), and need for tracheostomy (OR, 1.41; 95% CI, 2.21-7.67). The overall complication rate was 11% (9% in the selective group vs. 13% in the preselective group, p = 0.2574) and was highest following open SFT placement (22%).

CONCLUSION

A selective placement strategy for SFTs in our trauma population resulted in fewer unnecessary SFTs and a trend toward fewer complications. Surgical feeding tubes should be placed through a percutaneous approach whenever possible.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique

Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.

Feeding catheter gastrostomy with the round ligament of the liver prevents mechanical bowel obstruction after esophagectomy

Jejunostomy, which requires the fixation of the jejunum to the abdominal wall, is commonly used as an enteral feeding access after esophagectomy. However, this procedure sometimes causes severe complications, such as mechanical bowel obstruction. In 2009, we developed a modified approach to insert an enteral feeding tube through the reconstructed gastric tube using the round ligament of the liver. The aim of this study is to investigate the usefulness of this approach as compared to the approach through jejunostomy. Between January 2005 and March 2015, 420 patients with thoracic esophageal cancer underwent esophagectomy via thoracotomy and laparotomy. Of these, 214 underwent feeding jejunostomy (FJ group) and 206 patients underwent feeding via gastric tube with round ligament of the liver (FG group). Catheter-related complications, other postoperative complications, and mortality were compared between the two groups. The incidence of catheter site infection during catheterization in the FG group was significantly lower (n = 1/206, 0.5%) compared to the FJ group (n = 11/214, 5.1%) (P < 0.01). The postoperative bowel obstruction did not occur in the FG group, while it occurred in eight patients (3.7%) in the FJ group (P < 0.01). The incidences of other catheter-related and postoperative complications were similar between the two groups. Feeding catheter gastrostomy with the round ligament of the liver can be a useful enteral feeding access after esophagectomy, because the incidence rate of severe catheter-related complications, such as surgical site infection and mechanical obstruction tend to be lower with this technique compare to jejunostomy.

Nutrition Support in Adult Trauma Patients

Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. The purpose of this paper is to critically review the literature studying the use of enteral vs parenteral nutrition (PN) and to provide the rationale for early enteral nutrition. Additional controversies confronting clinicians are reviewed, including the use of immune-enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence-based recommendations for clinical practice are presented when available.

Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries

OBJECTIVE

The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies.

METHODS

Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN.

RESULTS

Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13).

CONCLUSION

The majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.

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.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery

INTRODUCTION

Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals.

PATIENTS AND METHODS

The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ).

RESULTS

Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived.

CONCLUSIONS

The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Injuries to the Pancreaticoduodenal Complex

Injuries to the pancreaticoduodenal complex present a significant challenge both in diagnosis and management. The retroperitoneal location of the pancreas means that it is not a common site of injury, but this also contributes to the difficulty in diagnosis, as the organ is concealed, and investigation often results in delay with its attendant increase in morbidity. The increase in violence in society, particularly of penetrating injuries and the increase in energy of wounding from gunshots, has made pancreatic injury more common. In many cases the surgical management is relatively simple, but occasionally complex and technical surgical solutions are necessary and the position of the pancreas makes its access and all procedures on it challenging. To compound this, pancreatic trauma is associated with a high incidence of injury to adjoining organs and major vascular structures, which adds to the high morbidity and mortality, and complications occur in 30-60% of patients [1, 2].

Colojejunal Fistula Resulting from a D-PEJ Feeding Tube

Numerous procedures have been developed to provide adequate enteral nutrition to patients with gastrointestinal disorders. Previously, operative placement of a feeding gastrostomy or jejunostomy tube was the accepted means of gaining chronic enteral access. However, improved technology and experience with endoscopic techniques have quickly replaced primary operative placement of enteral access. Direct percutaneous endoscopic jejunostomy (D-PEJ) is a procedure that was designed to deliver enteral feeding solutions for patients with proximal disease after unsatisfactory results from percutaneous endoscopic gastrostomy tubes with jejunal extensions (PEG-J). As with any procedure, it is associated with complications. We present the first reported case of a colojejunal fistula resulting from a D-PEJ placement. While D-PEJ has been shown to be relatively safe, complications related to the inherent limitations of the procedure need to be considered when the patient experiences unusual post-procedure symptoms and worked up appropriately.

Gastric versus postpyloric feeding

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.

Knot formation in the feeding jejunostomy tube: A case report and review of the literature

Jejunostomy feeding tubes provide surgeons with an excellent method for providing nutritional support, but there are several complications associated with a tube jejunostomy, including complications resulting from placement of the tube, mechanical problems related to the location or function and development of focally thickened small-bowel folds. A 76-year old man who presented with multiple medical diseases was admitted to our hospital due to aspiration pneumonia with acute respiratory failure and septic shock. He underwent exploratory laparotomy with feeding jejunostomy using a 14-French nasogastric tube for nutritional support. However, occlusion of the feeding tube was found 30 d after operation, and a rare complication of knot formation in the tube occurred after a new tube was replaced. On the following day, the tube was removed and replaced with a similar tube, which was placed into the jejunum for only 15 cm. The patient’s feedings were maintained smoothly for two months. Knot formation in the feeding tube seems to be very rare. To our knowledge, this is the third case in the literature review. Its incidence is probably related to the length of the tube inserted into the lumen.

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths

OBJECTIVE

To identify patterns of errors contributing to inpatient trauma deaths.

METHODS

All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data.

RESULTS

In 9 years, there were 44,401 trauma patient admissions and 2,594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.

CONCLUSIONS

Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

Abdominal CT as a predictor of outcome before attempted direct percutaneous endoscopic jejunostomy

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) placement succeeds in 72% to 86% of attempts. Failure is most often because of inadequate transillumination or gastroduodenal obstruction. Even in failed cases, patients are exposed to the risks of anesthesia, exploratory percutaneous needle punctures, and the cost burden of suboptimal resource utilization. Hence, a preprocedure predictor of outcome would be useful.

OBJECTIVE

To evaluate whether review of clinically available abdominal CTs can predict the outcome of subsequent DPEJ attempts.

DESIGN

Retrospectively conducted blinded review of abdominal CTs performed within 30 days before attempted DPEJ. Objective anatomic features potentially pertinent to DPEJ success were scored, and a prediction of the anticipated procedural outcome was made.

SETTING

A large tertiary referral center.

PATIENTS

A total of 115 patients who underwent attempted DPEJ and who also had an abdominal CT in the preceding 30 days.

MAIN OUTCOME MEASUREMENTS

Reviewer's overall prediction of success, 3 objective anatomic measurements.

RESULTS

For the overall prediction of success, a CT performed poorly, with a sensitivity of 60%, a specificity of 53%, a positive predictive value of 71%, and a negative predictive value of 40%. Mean abdominal-wall thickness was significantly greater in the failures than the successes (27 vs 21 mm, P = .02), and just 39% of the procedures in patients with an abdominal-wall thickness >3 cm were successful.

LIMITATIONS

Retrospective.

CONCLUSIONS

Failed DPEJ attempts were associated with greater patient abdominal-wall thickness, and this should be taken into consideration before attempted DPEJ. Otherwise, review of existing abdominal CTs appears to have limited utility in predicting DPEJ outcome.

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: 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.

Nutrición enteral con yeyunostomía con catéter de aguja en la anastomosis esofágica. Complicaciones de la técnica

OBJECTIVE

The aim of this study was to evaluate the presence of complications associated with the use of surgical needle catheter jejunostomy and tolerance to enteral nutrition.

PATIENTS AND METHOD

We performed a retrospective study of 58 consecutive patients, who underwent esophageal or gastric resection with esophageal anastomosis and needle catheter jejunostomy. The variables studied were initiation of enteral nutrition, duration of perfusion, complications associated with the use of jejunostomy, and tolerance to enteral nutrition.

RESULTS

Mortality in the series was 1.7%. Infusion of enteral nutrition was started at mean of 4.84+/-5.01 days and lasted for a mean of 7.9+/-7.5 days. In one patient the jejunostomy could not be used due to catheter obstruction and in another 2 patients some resistance to perfusion of nutrition was observed but these patients could be fed through the tube. One patient had to undergo reintervention due to peritonitis caused by extravasation of the enteral nutrition within the peritoneal cavity. Catheter withdrawal was difficult in 2 patients; of these, 1 patient required investigation of the skin wound under local anesthetic. The overall rate of jejunostomy-related complications was 10.3%. Tolerance of enteral nutrition was acceptable in 41 patients, the infusion rate was reduced in 6 patients and infusion was discontinued due to intolerance in 10.

CONCLUSIONS

Because needle catheter jejunostomy produces low morbidity and good tolerance to enteral nutrition, it is a valid alternative in patients with esophageal anastomosis.

Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive closure

BACKGROUND

Critically injured patients are susceptible to the abdominal compartment syndrome (ACS), which requires decompressive laparotomy with delayed abdominal closure. Previous work by the University of Texas Houston group showed impaired gut function after resuscitation-associated gut edema. The purpose of this study was to determine if enteral nutrition was precluded by the intra-abdominal hypertension and bowel edema of the ACS.

METHODS

Patients developing postinjury ACS from January 1996 to August 2003 at our level-I trauma center were reviewed. Patient demographics, time to definitive abdominal closure, and institution and tolerance of enteral nutrition were evaluated.

RESULTS

Thirty-seven patients developed postinjury ACS during the study period; 26 men and 11 women with a mean age of 36 +/- 4 and injury severity score of 33 +/- 4. Mean intra-abdominal pressure before decompression was 32 +/- 3 mm Hg, and concurrent mean peak airway pressure was 50 +/- 4 cm oxygen. Enteral feeding was never started in 12 patients; 4 died within 48 hours of admission, 7 required vasoactive agents until their death, and 1 developed an enterocutaneous fistula requiring parenteral nutrition. Enteral feeding was initiated in the remaining 25 patients: 13 had feeds started within 24 hours of abdominal closure; 5 were fed with open abdomens; and 7 had a delay because of vasopressors (n = 2), multiple trips to the operating room (n = 2), paralytics (n = 2), and increased intra-abdominal pressures (n = 1). Once advanced, enteral feeding was tolerated in 23 (92%) of the 25 patients with attainment of goal feeds in a mean of 3.1 +/- 1 days.

CONCLUSIONS

Despite the bowel edema and intra-abdominal hypertension related to the ACS, early enteral feeding is feasible after definitive abdominal closure.

A Modern Analysis of Morbidity after Pancreatic Resection

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and χ2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 ± 13.1 vs 17.4 ± 12.2 days, P < 0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 ± 16.9 vs 15.8 ± 9.9 days, P < 0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications—many of which are potentially preventable.

A prospective cohort study of feeding needle catheter jejunostomy in an upper gastrointestinal surgical unit

BACKGROUND & AIM

Feeding jejunostomy is recommended to facilitate early enteral nutrition after major upper gastrointestinal surgery. We aimed to determine the benefits and risks associated with routine practice of feeding needle catheter jejunostomy (NCJ) in high-risk upper gastrointestinal surgery.

METHOD

This is a prospective consecutive cohort study of 84 patients underwent feeding NCJ over a 3 years period in an Upper Gastrointestinal Surgical Unit.

RESULTS

Feeding NCJ was placed after two-stage oesophago-gastrectomy in 24 patients (28.6%), after gastrectomy in 29 patients (34.5%), after liver resections in 7 patients (8.3%), pancreatic resection in 6 patients (7.1%), bile duct reconstruction in 8 patients (9.5%) and other operations in 10 patients (12%). The mean (SE) estimated nutritional requirement per 24 h was 1791 (31)kcal. Eighty-two patients (98%) started enteral feed on day 1 after surgery. Fifty-seven patients (68%) achieved the target nutritional requirements in 3 days. Four patients were discharged home on jejunal feed whilst only two patients required parenteral nutrition support. The rest tolerated full oral diet. There was no procedure related mortality. The morbidity related to feeding tube and feeding were 12.9% and 20%, respectively.

CONCLUSIONS

Routine practice of feeding NCJ is safe. Their benefits outweigh the risks in a specialist centre.

Nutritional support of the critically ill and injured patient

The understanding of the importance of nutrition, particularly in the critically ill patient, is based on the known physiologic consequences of malnutrition. It includes respiratory muscle function, cardiac function, the coagulation cascade balance, electrolyte and hormonal balance, and renal function. Nutrition affects emotional and behavioral responses, functional recovery, and the overall cost of health care. The need to identify and treat the malnourished or potentially malnourished patient is a critical aspect of patient management. Much is known of catabolic and hypermetabolic state caused by trauma and burns. The response to injury needs to be mediated. There is much to learn about the intervention of that response through adjuvant nutritional therapy.

Hypoxia differentially regulates nutrient transport in rat jejunum regardless of luminal nutrient present

Aggressive enteral nutrition and poor intestinal perfusion are hypothesized to play an important pathogenic role in nonocclusive small bowel necrosis. This study tests the hypothesis that glucose and glutamine transport are differentially regulated during hypoxia regardless of the luminal nutrient present. Sprague-Dawley rats (247 +/- 3 g; n = 16) were randomized to receive 1 h of intestinal hypoxia or serve as normoxic controls. During this hour, jejunal loops were randomized to receive in situ perfusions of mannitol, glucose, or glutamine. When compared with normoxic groups, glucose but not glutamine transport was impaired (P < 0.001) during hypoxia. Messenger RNA abundance of the sodium glucose cotransporter sodium-dependent glucose cotransporter-1 (SGLT-1) and neutral basic amino acid transporter B(o) did not differ with hypoxia or nutrient perfused. Jejunal brush-border SGLT-1 abundance was decreased (P = 0.039) with hypoxia; however, total cellular SGLT-1 protein abundance did not differ among treatment groups. These data indicate that SGLT-1 activity is regulated during hypoxia at the posttranslational level. Additional information regarding the mechanisms regulating nutrient transport in the hypoperfused intestine is critical for optimizing the composition of enteral nutrient formulas.

Postinjury enteral tolerance is reliably achieved by a standardized protocol

BACKGROUND

Postinjury enteral nutrition (EN) is beneficial. Unfortunately, severely injured patients who should benefit most are frequently intolerant. To assist in maximizing enteral tolerance in the critically injured, we first implemented a prospective analysis of the effectiveness of a standardized enteral protocol (EP) at a single institution followed by a prospective multi-institutional analysis of its implementation.

METHODS

Tolerance parameters were prospectively collected on severely injured patients at a single (Phase I) and then multiple (Phase II) institutions. EN was begun at 15 cc/h and advanced every 12 h to a patient specific targeted goal. Intolerance symptoms (high nasogastric output/emesis, abdominal distention, and diarrhea) were assessed and graded every 12 h and managed using a standardized protocol. Tolerance was characterized as early (during initial advancement of feeds) or late (after standard goal) and classified as good (EN advanced per EP), moderate (rate decreased per EP), poor (EN held per EP), or EN discontinued (and TPN begun).

RESULTS

In Phase I patients (ISS = 25 +/- 3) early tolerance was good in 82% (14/17) while late good tolerance decreased to 65% (11/17). In Phase II patients (ISS = 30 +/- 2), early tolerance was good in 85% (41/49) and late tolerance was good in 80% (39/49). Moderate intolerance was primarily seen in Phase II patients and due to high gastric output in patients fed proximal to the ligament of Treitz (13/16). Overall 88% (15/17) of Phase I and 100% (49/49) of Phase II patients were successfully maintained on EN.

CONCLUSIONS

Severely injured patients exhibited good tolerance to EN when managed using a standardized protocol at four Level I trauma centers. Moderate intolerance was associated with high gastric output and may be lessened by feeding distal to the ligament of Treitz.

Evaluation of patients with jejunostomy tubes: imaging findings

PURPOSE

To determine the frequency and nature of abnormalities observed on radiographs after placement of jejunostomy (J) tubes for enteral nutrition.

MATERIALS AND METHODS

Radiology database review revealed that 280 studies of the J tube or of the small bowel with water-soluble contrast material and/or barium sulfate were performed in patients during 10 years. Review of the radiologic reports revealed abnormalities related to the placement of tubes in 105 (38%) cases. Images were reviewed to determine abnormalities in these 105 cases. Radiologic, medical, and surgical records were also reviewed to determine the clinical course and any subsequent interventions.

RESULTS

One or more complications were detected in 40 (14%) of 280 cases: small-bowel obstruction in 17 (6%) cases, nonobstructive small-bowel narrowing in six (2%), extraluminal tracks or collections in seven (2%), extravasation of contrast material to the skin in 11 (4%), jejunal hematomas in five (2%), and intussusceptions in four (1%). Mechanical problems related to the tube were detected in 52 (19%) cases, including coiling, kinking, or knotting of the tube in 38 (14%), malpositioning in five (2%), retrograde flow in four (1%), occlusion in four (1%), and a hole in one (<1%). Focal thickening of small-bowel folds was detected in 24 (9%) cases.

CONCLUSION

Radiographs in 280 patients with J tubes revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases).

Provision of phosphorylatable substrate during hypoxia decreases jejunal barrier function

OBJECTIVES

There is an emerging consensus that early enteral nutrition benefits the high-risk surgical patient. However, in patients with inadequate gastrointestinal perfusion, food in the intestine may increase the oxygen demand beyond that which can be satisfied by the available delivery, potentially leading to intestinal malfunction. The effect of metabolic substrate on gastrointestinal function during various oxygenation states was investigated.

METHODS

Jejunal samples obtained from 32 male Sprague-Dawley rats (263 +/- Q15 g) were stripped of the muscularis, mounted in modified Ussing chambers, and randomized to be incubated in media equilibrated with one of four gas mixtures (95%, 75%, 50%, and 25% oxygen). After equilibration, fluorescent probes (4400 and 17 200 molecular weight [MW]) were added to the incubation media on the mucosal side. The rate of probe accumulation on the serosal side was determined before and after the addition of one of four substrates to the mucosal medium: mannitol (an osmotic control), glucose (which is transported, phosphorylated, and metabolized), 2-deoxyglucose (a glucose analog that is transported and phosphorylated but not metabolized), or 3-O-methylglucose (a glucose analog that is transported but not phosphorylated or metabolized).

RESULTS

Lumenal glucose, 2-deoxyglucose, and 3-O-methylglucose increased permeation of the 4400-MW probe at all oxygen levels, whereas mannitol did not alter permeation in the 95% and 75% oxygen groups. Lumenal glucose increased (P < 0.05) the permeation rate of the 17 200-MW probe at all oxygen levels, whereas 2-deoxyglucose and 3-O-methylglucose did not increase the permeation rate of the 17 200-MW probe until oxygen was lowered to 75% and 50%, respectively. Regardless of substrate treatment, jejunal permeation of the 4400-MW (P < 0.001) and 17 200-MW (P < 0.05) probes increased in the 25% and 50% oxygen groups compared with the 75% and 95% oxygen groups.

CONCLUSIONS

These initial results suggest that the provision of lumenal nutrients exacerbates the loss of gastrointestinal barrier function during hypoxia. Although the early provision of nutrients is an important intervention in acutely injured patients, care must be taken to ensure that gastrointestinal perfusion is adequate to allow substrate metabolism and prevent further compromise in gastrointestinal function.

Migrating motility complexes persist after severe traumatic shock in patients who tolerate enteral nutrition

BACKGROUND

Postinjury small bowel ileus is poorly characterized and may be an important factor in intolerance to enteral nutrition (EN). We, therefore, placed jejunal manometry catheters in high-risk trauma patients. Our hypothesis was that the presence of "fasting migrating motility complex (MMC)" activity and conversion to a "fed pattern" at goal rate of EN would be present in those patients who tolerate jejunal feeding.

METHODS

After obtaining baseline fasting manometry pressure tracings, jejunal feeding was advanced stepwise to a set goal while tolerance was monitored and intolerance was treated by a standard approach.

RESULTS

Of the 10 study patients, 7 were able to be maintained on EN. Five (50%) had "fasting MMCs" and had good tolerance to early advancement of EN. The remaining five patients did not exhibit "fasting MMCs" and four had poor tolerance to early advancement of EN. Overall, nine patients reached goal rate of EN of which four converted to a "fed pattern." This, however, was not associated with later tolerance to EN.

CONCLUSION

EN is feasible following severe traumatic shock. Surprisingly, half of the patients had fasting MMCs. This requires intact neural and motor function and was associated with good tolerance of early EN.

Trauma intensive care

Management of the traumatically injured patient in the intensive care unit is a complex and challenging area of general surgery. The problems encountered in the intensive care unit are the source of exciting clinical and basic science research. The future of caring for the severely injured patient suffering from the complications of trauma will undoubtedly further bond the art of clinical medicine to the accomplishments of developing technology and molecular biology.