Jejunostomy: techniques, indications, and complications.
Jejunostomy is a surgical procedure by which a tube is situated in the lumen of the proximal jejunum, primarily to administer nutrition. There are many techniques used for jejunostomy: longitudinal Witzel, transverse Witzel, open gastrojejunostomy, needle catheter technique, percutaneous endoscopy, and laparoscopy. The principal indication for a jejunostomy is as an additional procedure during major surgery of the upper digestive tract, where irrespective of the pathology or surgical procedures of the esophagus, stomach, duodenum, pancreas, liver, and biliary tracts, nutrition can be infused at the level of the jejunum. It is also used in laparotomy patients in whom a complicated postoperatory recovery is expected, those with a prolonged fasting period, those in a hypercatabolic state, or those who will subsequently need chemotherapy or radiotherapy. As a sole procedure it is advised for neurologic and congenital illnesses, in geriatric patients who pose difficult care demands, and for patients with tumors of the head and neck. The complications seen with jejunostomy can be mechanical, infectious, gastrointestinal, or metabolic. The rate of technical complications of the Witzel longitudinal technique is 2.1%, for the transverse Witzel up to 6.6%, for the Roux-en-Y 21%, for open gastrojejunostomy from 2%, and for the needle catheter technique from 1.5% with 0.14% mortality. The percutaneous endoscopic procedures have as much as a 12% complication rate; no figures exist for laparoscopy. The complications are moderate and severe: tube dislocation, obstruction or migration of the tube, cutaneous or intraabdominal abscesses, enterocutaneous fistulas, pneumatosis, occlusion, and intestinal ischemia. The infectious complications are aspiration pneumonia and contamination of the diet. The gastrointestinal complications are diarrhea 2.3% to 6.8%, abdominal distension, colic, constipation, nausea, and vomiting. The metabolic complications are hyperglycemia 29%, hypokalemia 50%, water and electrolyte imbalance, hypophosphatemia, and hypomagnesemia. These complications are secondary to inadequate selection of nutrition relative to the characteristics of the patient, to inadequate management of the mixture, and to deficient clinical care. The ideal jejunostomy technique depends on the material resources but more importantly on the experience of the surgeon. The benefits of jejunostomy justify the risks.
Tapia
J
J
Nutritional Support Department, Hospital de Especialidades del Centro Medico Nacional, Mexican Institute of Social Security (IMSS), Avenida Cuauhtemoc 330, Col. Doctores, CP 06720 Mexico, D.F., Mexico.
Murguia
R
R
Garcia
G
G
de los Monteros
P E
PE
Oñate
E
E
D000368:Aged; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000145:classification / Q000379:methods; D002404:Catheterization / Q000009:adverse effects / Q000295:instrumentation; D017024:Chemotherapy, Adjuvant; D000075202:Contraindications; D013505:Digestive System Surgical Procedures; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000379:methods; D004750:Enteral Nutrition / Q000009:adverse effects / Q000145:classification / Q000379:methods; D005215:Fasting; D006801:Humans; D007582:Jejunostomy / Q000009:adverse effects / Q000145:classification / Q000379:methods; D010535:Laparoscopy; D007813:Laparotomy; D009339:Needles / Q000009:adverse effects; D009747:Nutritional Physiological Phenomena; D018714:Radiotherapy, Adjuvant; D012307:Risk Factors