title: Jejunostomy tube placement in refractory diabetic gastroparesis: a retrospective review.
abstract: OBJECTIVE
  Severe diabetic gastroparesis leading to recurrent episodes of diabetic ketoacidosis and frequent hospitalizations can be among the most disabling of all diabetic complications. Surgical placement of a jejunostomy tube (J-tube) beyond the affected stomach to deliver fluid, nutrients, and medication is one of the few therapeutic options remaining in the cohort of patients who have failed standard medical therapy. This study attempts to define the natural history of refractory diabetic gastroparesis and the risks and benefits of J-tube placement.
  
  
  METHODS
  A total of 26 patients with diabetic gastroparesis requiring J-tube placement were identified between 1980 and 1994. Medical chart review and telephone follow-up were performed using standardized questionnaires.
  
  
  RESULTS
  All patients had documented delayed gastric emptying, had failed medical therapy, and had been hospitalized on multiple occasions. Neuropathy, retinopathy, and nephropathy were observed in 88%, 81%, and 65% of patients, respectively. The mean duration of study follow-up was 47 months (1-130 months). The mean age of subjects at the time of J-tube placement was 31 yr, and a preponderance of female patients (73%) was noted. There were 23 major complications in 14 patients requiring surgery or hospitalization and 47 minor complications in 21 patients managed on an outpatient basis. The mean duration of J-tube use was 20 months. There were 10 deaths during follow-up, one related to J-tube placement. Retrospectively, 39% reported improved symptoms of nausea/vomiting (4% worsened), 52% reported fewer hospitalizations (4%, more frequent), 56% reported improved nutritional status (4% worsened), and 83% reported improved overall health (4% worsened) after J-tube placement. The improvement in overall health status was the only symptom that reached statistical significance.
  
  
  CONCLUSIONS
  Severe refractory gastroparesis is associated with multiple hospitalizations, a high incidence of concomitant diabetic complications, and a mortality rate of 38% at 4 yr. There is a high incidence of complications following J-tube placement in this population. Despite this, most patients retrospectively reported improved overall health after J-tube placement. Therefore, placement of a J-tube may be a workable option with acceptable perioperative morbidity and mortality rates in selected patients with severe diabetic gastroparesis who have failed medical therapy. A prospective study of J-tube placement and other available means of nutritional support is needed to demonstrate further the efficacy of this intervention in patients with severe diabetic gastroparesis.
authors.affiliation: Gastroenterology Division, University of Michigan Medical Center, Ann Arbor, USA.
authors.forename: R J
authors.initials: RJ
authors.lastname: Fontana
authors.forename: J L
authors.initials: JL
authors.lastname: Barnett
mesh_terms: D000328:Adult; D048909:Diabetes Complications; D005260:Female; D005500:Follow-Up Studies; D018589:Gastroparesis / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects; D007582:Jejunostomy / Q000009:adverse effects; D008297:Male; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome