Complications of Feeding Complications of Feeding Jejunostomies

N. Dayes

King County Medical CenterKing County Medical Center

Trauma Service

ES 1961241

85 y.o. female nursing home resident.

Past Medical Hx – Afib, HTN, CVA

Admitted for 2nd acute embolic CVA with residual left h i i d h ihemiparesis and aphasia.

Referred to the GI service for PEG placement for enteral Referred to the GI service for PEG placement for enteral nutrition.

ES 1961241ES 1961241The patient suffered a gastric perforation during this procedure and a surgery consult was called.

WBC 8 85WBC – 8.85

H/H – 12.3/38

Plt 264Plt – 264

Na – 145, K – 3.5, Cl -106, bicarb – 23,

BUN/Cr – 22/0 63BUN/Cr 22/0.63

7.485/36.5/122/98/28/3.8

X rayX-ray

ES 1961241ES 1961241HOD # 10 -Taken to OR for exploratory laparotomy, gastric wedge resection, and feeding jejunostomy placement.

HOD# 11/POD #1 I b d N h HOD# 11/POD #1 – Intubated, Normotensive with a normal heart rate. Adequate urine output.

POD# 2 – Jejunostomy feeds were started.

ES 1961241ES 1961241POD#6 –

The patient became oliguric with a WBC 13. She was also hypotensive requiring pressor support.

Broad spectrum antibiotics were started . CVP and arterial line were placed for monitoring.

Abdominal exam revealed a soft, distended abdomen.

ES 1961241ES 1961241POD#6 –

Na – 146, K- 4.7, Cl – 115, Bicarb – 18, Glc – 79

BUN/Cr 46/1 71BUN/Cr – 46/1.71

7.232/38/110/97%/15.9/-10.5

Emergent abdomen/pelvis CT-scan ……….

ES 1961241ES 1961241POD#6 –

T k l h O f l l h h Taken emergently to the OR for exploratory laparotomy which revealed a displaced jejunostomy tube.

Previous jejunostomy site was closed in a two-layered fashion.

Enteral feeds noted throughout abdomenEnteral feeds noted throughout abdomen.

Copious irrigation

New feeding jejunostomy was placed distal to the old site.

ES 1961241ES 1961241HOD # 21/POD# 1 –WBC -10 , decreasing pressor support. Good urine output.

HOD#35 T h f d dHOD#35 -Tracheotomy for respiratory dependence.

HOD #50 Di h d t i h f ilitHOD #50 - Discharged to nursing home facility.

DiscussionDiscussionOptions for post-op enteral feeding.

Techniques for jejunostomy insertion.

Complications.

Is a jejunostomy a safe method?

Options for post op enteral feedingOptions for post-op enteral feedingNasogastric tube.

Gastrostomy.PEG ( d i )PEG (percutaneous endoscopic gastrostomy).Open.

Stamm.

Janeway.

Jejunostomy.Bush in 1858.

Surgical Jejunostomy in Aspiration Risk PatientsPatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992

Retrospective chart review of 100 patients from 5/1987 to 6/1990.

All were at risk for aspiration pneumonia.

All jejunostomies were performed by a single surgeon using a uniform techniqueuniform technique.

Major end-point was aspiration pneumonia Major end-point was aspiration pneumonia.

Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992Weltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992

Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992Weltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992

Analysis of this retrospective review reported an 8% incidence of postoperative aspiration pneumonia.

Compared to previously reported 23 to 40% incidence of aspiration pneumonia associated with percutaneous aspiration pneumonia associated with percutaneous gastrostomy tubes.1-2

1 Cogen R, Weinryb J. aspiration pneumonia in nursing home patients fed via gastrostomy tubes. Am J Gastro 1989; 84:1509-15122 Ci JO Sil t FA F l CJ T b f di i ld l ti t2 Ciocon JO, Silverstone FA, Foley CJ. Tube feedings in elderly patients. Arch intern Med 1988; 148:429-433.

T h i f j j t i tiTechniques for jejunostomy insertionLaparotomy

d l lLongitudinal Witzel

Transverse Witzel

Needle catheter

Percutaneous endoscopy gastrojejunostomy placementpy g j j y p

Laparoscopy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Witzel JejunostomyWitzel Jejunostomy

Needle JejunostomyNeedle Jejunostomy

Needle JejunostomyNeedle Jejunostomy

Complications Complications Mechanical

Intestinal occlusion

Intraperitoneal leakageIntraperitoneal leakage

Local abscess collection

Intestinal necrosis

[1] – Gerdt, SJ, Orringer, MB. Tube jejunostomy as and adjunct to esophagectomy, g j j y j p g ySurgery 115:164,1994

C li ti IIComplications II

InfectiousInfectiousAspiration Pneumonia

GastrointestinalAbdominal distention

Diarrhea

Constipation

Is a jejunostomy a safe method?Is a jejunostomy a safe method?Complications of Needle Catheter Jejunostomy in 2,022 Consecutive ApplicationsApplications.

Myer JG, Aust B, et.al. Amer J Surg 170:1995

Large retrospective review of patient charts from 1978 to 1994.

All jejunostomies were inserted by a staff physician using a All jejunostomies were inserted by a staff physician using a similar commercially available kit.

Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995

Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995

Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995

Concluded that jejunostomies are a safe and effective means of providing nutritional support.

E h h h l d d l l Emphasis on the mechanical aspects and radiological confirmation.

ConclusionConclusionPost –pyloric feeding is advantageous in patients with a high risk of aspiration.

A f d b d d f d ff A feeding jejunostomy can be considered safe and effective routes for enteral feeding.

While a safe approach, a feeding jejunostomy, as with all invasive procedures, is not risk free.p ,

ReferencesReferencesComplications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications Myer JG Aust B et al Amer J Surg 170:1995Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995

Gerdt, SJ, Orringer, MB. Tube jejunostomy as and adjunct to esophagectomy, Surgery 115:164,1994.

S l A k Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992

Cogen R, Weinryb J. aspiration pneumonia in nursing home patients fed via bgastrostomy tubes. Am J Gastro 1989; 84:1509-1512

Ciocon JO, Silverstone FA, Foley CJ. Tube feedings in elderly patients. Arch intern Med 1988; 148:429-433.

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