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Jejunostomy

A jejunostomy is a surgical procedure in which a feeding tube is inserted through the abdominal wall into the jejunum, the proximal portion of the small intestine, to deliver enteral nutrition or medications directly into the digestive tract, bypassing the stomach and esophagus.^[1] This method ensures nutrient absorption in patients unable to eat orally or via gastric routes, such as those with prolonged swallowing difficulties or gastrointestinal obstructions.^[2] Jejunostomy tubes are indicated for long-term nutritional support exceeding six weeks, particularly following major upper gastrointestinal surgeries like esophagectomy or gastrectomy, or in conditions including gastric outlet obstruction, gastroparesis, and severe malnutrition where nasoenteral access is impractical or impossible.^[1] Contraindications include absolute factors like distal bowel obstruction and relative ones such as active abdominal wall infection, severe coagulopathy (INR >1.5), or hemodynamic instability.^[1] The procedure can be performed via open surgery, laparoscopy, or percutaneous techniques, with the Witzel method—first described in 1891—commonly used to create a secure anti-reflux tunnel by folding the jejunum over the tube site.^[1] Historically, the first jejunostomy was conducted by A.S. Bush in 1858 for inoperable gastric cancer, marking an early advancement in enteral feeding despite high initial complication rates.^[1] Modern placements prioritize multidisciplinary care involving surgeons, dietitians, and nurses to optimize outcomes, though risks persist, including mechanical issues like tube occlusion or dislodgement, infectious complications such as site infections or aspiration pneumonia, and metabolic disturbances like refeeding syndrome.^[1] Proper post-procedure management, including daily site cleaning and tube flushing, is essential to mitigate these, with home enteral nutrition programs improving outcomes.^[2]^[1]

Overview

Definition

A jejunostomy is the surgical creation of an opening, or stoma, through the abdominal wall directly into the jejunum, the middle portion of the small intestine.^[3] This procedure allows for the insertion of a feeding tube into the jejunum to bypass the upper gastrointestinal tract when necessary.^[1] The jejunum is the middle portion of the small intestine, immediately following the duodenum and preceding the ileum, and it plays a critical role in nutrient absorption, primarily handling carbohydrates, proteins, fats, vitamins, minerals, and water from partially digested food.^[4] Its extensive surface area, enhanced by circular folds (plicae circulares) and villi, facilitates efficient uptake of these nutrients into the bloodstream.^[5] The primary purposes of a jejunostomy include providing enteral nutrition, delivering medications, or facilitating decompression of the gastrointestinal tract in scenarios where oral intake or gastric access is not feasible.^[1] Jejunostomies can be classified as temporary, often used for short-term support such as post-surgical recovery lasting several weeks, or permanent for long-term needs exceeding months.^[6] They may also be designated as feeding types for nutritional delivery or decompressive types to relieve intestinal pressure, particularly after complex abdominal surgeries.^[7] In contrast to gastrostomy, which provides access to the stomach, jejunostomy targets the small intestine to avoid upper gut obstructions.^[1]

Indications

Jejunostomy is indicated when enteral nutrition cannot be adequately provided through the oral route or via gastric access, such as in cases where nasoenteral tubes are impractical for long-term use or when anticipated nutritional support exceeds six weeks.^[1] It serves as an alternative to gastrostomy by bypassing the stomach, particularly in patients with impaired gastric function, to reduce risks like aspiration and ensure direct delivery of nutrients to the small intestine.^[8] Common indications include conditions causing inability to utilize the stomach for feeding due to surgical interventions, mechanical obstructions, or underlying diseases. For instance, in esophageal cancer or gastric outlet obstruction from inoperable tumors, refractory peptic ulcers, or syndromes like Bouveret, jejunostomy provides a route for nutrition when the upper gastrointestinal tract is compromised.^[1] Similarly, post-upper gastrointestinal surgeries such as esophagectomy often necessitate jejunostomy placement to support recovery, as oral intake may be insufficient and gastric feeding contraindicated due to anastomotic risks or delayed emptying.^[9] Severe gastroesophageal reflux disease (GERD) with high aspiration risk represents another key scenario, where jejunostomy minimizes reflux-related complications by infusing feedings distal to the stomach, particularly in patients with gastroparesis or motility disorders.^[10] Neurological disorders impairing swallowing, such as amyotrophic lateral sclerosis (ALS) or stroke, may also warrant jejunostomy if gastric feeding exacerbates aspiration or when irreversible deficits prevent safe oral or gastric intake.^[11] In pediatric populations, jejunostomy is recommended for congenital anomalies like duodenal atresia, where surgical repair may require temporary or adjunctive enteral access to promote growth and trophic feeding.^[12] Gastroesophageal reflux or esophageal atresia in children with neurological impairment further supports its use as a bridge to oral feeding.^[13] Additional indications encompass pancreatitis with gastric intolerance, where jejunal feeding helps prevent ileus and supports gut function without stimulating pancreatic secretions, and radiation enteritis affecting gastric tolerance, necessitating distal access for nutrition.^[14]^[15]

Contraindications

Jejunostomy placement carries specific risks that necessitate careful patient selection, with absolute contraindications representing conditions where the procedure poses an unacceptable danger and should not be performed. These include uncorrectable coagulopathy, which significantly elevates the risk of life-threatening hemorrhage during tube insertion or manipulation.^[16] Active peritonitis is another absolute contraindication, as it indicates widespread intra-abdominal contamination that could be exacerbated by procedural intervention, leading to sepsis or further deterioration.^[17] Severe bowel ischemia, including mesenteric ischemia, is also prohibitive, since accessing the jejunum could worsen tissue necrosis and precipitate bowel perforation or gangrene.^[18] Additionally, mechanical bowel obstruction distal to the intended jejunostomy site constitutes an absolute barrier, preventing safe enteral feeding and risking proximal distension or rupture.^[1] Relative contraindications involve scenarios where the procedure may be feasible but requires heightened caution, weighing benefits against elevated risks. Active intra-abdominal infection, short of full peritonitis, is considered relative, as it may increase the likelihood of localized abscess formation or systemic spread post-procedure.^[19] Hemodynamic instability represents another relative concern, particularly in critically ill patients where anesthesia or procedural stress could precipitate cardiovascular collapse.^[17] Anatomical barriers, such as extensive adhesions from prior abdominal surgery or unfavorable bowel anatomy rendering the jejunum inaccessible, fall into this category, often necessitating alternative feeding routes or advanced imaging for assessment.^[20] Patient-specific factors further modulate risk in relative terms. Morbid obesity complicates access by obscuring landmarks and increasing technical difficulty, potentially prolonging operative time and wound complications.^[21] Poor nutritional status, common in candidates for enteral access, heightens overall surgical risk through impaired wound healing and immune function, though it does not preclude the procedure if benefits outweigh perils.^[22] For technique-specific considerations, endoscopic and radiologic approaches have unique relative hurdles. Inability to transilluminate the abdomen, often due to obesity or thick abdominal walls, hampers safe percutaneous guidance in radiologic jejunostomy.^[17] Indirect methods relying on gastric access, such as percutaneous endoscopic gastrojejunostomy, are relatively contraindicated when gastric pathology or prior surgery precludes stable transgastric passage to the jejunum.^[16]

History

Early Developments

The concept of jejunostomy emerged in the early 19th century as part of broader explorations into enterostomy procedures, which aimed to create surgical openings in the small intestine to address obstructions or nutritional deficits.^[23] These initial attempts were experimental and often unsuccessful, reflecting the era's limited understanding of antisepsis and intestinal anatomy.^[24] Jejunostomy drew influence from pioneering work in gastrostomy, first suggested by Norwegian surgeon Christian J. Egeberg in 1837 as a means to provide direct stomach access for feeding.^[25] French surgeon Charles Sédillot advanced this in 1845 by performing the first gastrostomy for nutritional purposes in a human patient, though the procedure involved significant leakage and short-term survival.^[26] The first successful feeding jejunostomy was performed in 1858 by surgeon Bush on a patient with inoperable stomach cancer, allowing enteral nutrition via a tube inserted into the jejunum and marking a viable clinical application.^[1] Despite this breakthrough, early jejunostomies faced severe challenges, including high mortality rates—often exceeding 50%—primarily due to peritonitis from bacterial contamination and leakage of intestinal contents caused by rudimentary suturing and closure techniques.^[24] These limitations stemmed from the absence of effective anesthesia, sterilization, and antibiotics, confining the procedure to desperate cases with poor outcomes.^[27]

Evolution of Techniques

The evolution of jejunostomy techniques began in the late 19th century with the introduction of the Witzel method in 1891, which established a foundational approach for surgical jejunostomy by creating an anti-reflux tunnel in the jejunal wall to minimize leakage and peritonitis risks.^[1] This open surgical technique involved tunneling a portion of the jejunum over the feeding tube and affixing it to the abdominal wall, marking a significant improvement over earlier direct stoma methods that suffered from high complication rates due to gastric reflux and infection.^[1] The Witzel technique remained the standard for open jejunostomy procedures into the 20th century, influencing subsequent modifications aimed at enhancing tube stability and nutritional delivery. The 1980s brought a paradigm shift with the development of percutaneous methods, inspired by the inaugural percutaneous endoscopic gastrostomy (PEG) procedure described by Gauderer et al. in 1980, which utilized endoscopy to place feeding tubes without laparotomy.^[28] This innovation rapidly adapted to the jejunum, leading to percutaneous endoscopic jejunostomy (PEJ) techniques that extended the endoscope beyond the stomach for direct jejunal access, reducing operative time and invasiveness compared to traditional surgery.^[1] By the late 1980s, direct percutaneous endoscopic jejunostomy (DPEJ), first reported by Shike et al. in 1987, further refined this approach by bypassing gastric placement altogether, allowing for more reliable postpyloric feeding in patients with gastric issues.^[21] Entering the 1990s and 2000s, laparoscopic techniques emerged as a key milestone, with the first laparoscopic jejunostomy described by O'Regan and Scarrow in 1990, combining minimally invasive visualization with secure tube placement to further decrease recovery times and wound complications.^[29] Concurrently, radiologic-guided methods like direct percutaneous radiologic jejunostomy gained traction, leveraging fluoroscopy for precise needle access to the jejunum, particularly in patients unsuitable for endoscopy.^[30] These advancements collectively reduced complication rates from over 50% in early procedures to 10-20% overall in modern minimally invasive variants.^[31] In the 21st century, refinements in imaging modalities such as fluoroscopy and ultrasound have enhanced procedural accuracy and safety, enabling real-time guidance for tube insertion and reducing risks like bowel perforation.^[20] Additionally, the adoption of advanced materials, including biocompatible silicone tubes with low-profile designs, has improved long-term patency and patient comfort, minimizing issues like tube migration and infection.^[32] These developments underscore a progression toward less invasive, more patient-centered jejunostomy practices.

Techniques

Endoscopic Techniques

Endoscopic techniques for jejunostomy placement provide minimally invasive alternatives to surgical methods, utilizing an endoscope to guide tube insertion directly or indirectly into the jejunum for enteral nutrition. These approaches are particularly valuable for patients requiring post-pyloric feeding to minimize aspiration risk, such as those with gastroparesis or severe gastroesophageal reflux disease.^[17] Percutaneous endoscopic jejunostomy (PEJ), often performed as an indirect method via percutaneous endoscopic gastrostomy with jejunal extension (PEG-J), involves advancing a jejunal tube through an existing or newly placed gastrostomy site into the jejunum. The procedure typically employs the "push" technique, where the endoscope navigates the tube beyond the pylorus, or a "pull" variant using a guidewire or snare for positioning. In contrast, direct percutaneous endoscopic jejunostomy (DPEJ) accesses the jejunum directly without relying on a gastric intermediary, often assisted by fluoroscopy to confirm positioning in cases of altered anatomy. DPEJ commonly uses a modified "pull" technique, similar to standard PEG placement but targeting the jejunal loop.^[30]^[17] The general steps for both PEJ and DPEJ begin with moderate sedation or general anesthesia, followed by oral insertion of a forward-viewing endoscope (such as a pediatric colonoscope or enteroscope) to visualize the jejunum. Transillumination from the endoscope identifies a suitable anterior jejunal loop through the abdominal wall, confirmed by external finger indentation to ensure no overlying organs. A needle punctures the abdominal wall into the jejunum under endoscopic guidance, through which a guidewire is advanced and snared. The tract is dilated, and the jejunostomy tube is pulled or pushed into place, secured internally with a bumper or balloon and externally with a fixation device to prevent migration. The procedure achieves technical success rates exceeding 95% for PEJ and approximately 87% for DPEJ, with clinical success in nutrition delivery nearing 97-99%.^[30]^[17] These endoscopic methods offer key advantages, including performance at the bedside or in an endoscopy suite, avoidance of laparotomy, and suitability for high-surgical-risk patients, thereby reducing procedural morbidity compared to open surgery. DPEJ, in particular, demonstrates lower tube malfunction rates (around 11%) than indirect PEJ (up to 24%), enhancing long-term reliability. Common devices include 12-18 Fr silicone or polyurethane tubes with internal bumpers or balloons for fixation, often from standard PEG kits adapted for jejunal use, such as those by Boston Scientific or Kimberly-Clark.^[30]^[17]

Surgical Techniques

Surgical jejunostomy involves creating a stoma in the jejunum through open or laparoscopic approaches to facilitate enteral feeding, typically when gastric access is contraindicated. The open technique, historically the gold standard, utilizes a midline laparotomy to access the peritoneal cavity, allowing direct visualization and manipulation of the jejunum.^[20] A loop of proximal jejunum is selected and delivered through the incision, with site selection ideally 20 to 40 cm distal to the ligament of Treitz to minimize duodenal reflux and optimize nutrient absorption.^[1] A small enterotomy is made in the antimesenteric border, and a feeding tube is inserted, secured initially with a purse-string suture using 3-0 silk to prevent leakage.^[32] For enhanced anti-reflux protection, the Witzel technique creates a tunneled seromuscular tunnel approximately 5 cm long along the jejunal wall, encasing the tube with interrupted Lembert sutures to form a valved pathway that reduces the risk of aspiration and peritonitis.^[1] The jejunum is then affixed to the anterior abdominal wall with four seromuscular sutures in a diamond configuration at the left upper quadrant exit site, followed by external tube fixation.^[33] This method typically requires general anesthesia and takes longer than minimally invasive alternatives, often exceeding 60 minutes due to the extensile incision and closure.^[34] Tube selection in open jejunostomy distinguishes non-tunneled from tunneled options. Non-tunneled tubes, such as simple 12- to 16-French silicone or rubber catheters, rely on basic purse-string fixation for short-term use, offering straightforward placement but higher leakage risk without additional tunneling.^[1] In contrast, tunneled tubes, commonly employed in the Witzel configuration, incorporate a serosal tunnel to promote tissue ingrowth and prevent retrograde flow, making them preferable for prolonged enteral nutrition.^[33] Balloon-tipped variants allow for easier replacement if dislodged, with inflation securing the tube internally.^[1] Laparoscopic jejunostomy provides a minimally invasive alternative, reducing postoperative pain and recovery time compared to open surgery, while maintaining direct visualization through ports.^[35] Under general anesthesia, pneumoperitoneum is established via a 10-mm infraumbilical port, followed by insertion of additional ports: a 10-mm camera port in the right anterior axillary line, two 5-mm working ports in the right mid-clavicular line, and a 5-mm port at the planned left upper quadrant exit site.^[34] The ligament of Treitz is identified, and a jejunal loop 20 to 40 cm distal is mobilized and anchored to the anterior abdominal wall with a 3-0 polyglactin stay suture to minimize tension.^[33] An enterotomy is created 6 to 8 cm distal to the anchor point, and the tube is advanced intracorporeally using a Seldinger technique: a needle introduces a guidewire, followed by serial dilation and placement of a peel-away sheath through which a 14-French tube is threaded.^[36] Securement mirrors open methods, with a purse-string suture at the enterotomy and optional Witzel tunneling using 3-4 interrupted vicryl stitches along the bowel to encase the tube, avoiding direct incorporation to prevent obstruction.^[34] The jejunum is tacked to the peritoneum and fascia with three-point fixation sutures, and the tube is exteriorized, tested for patency with air or saline.^[33] Procedure duration generally ranges from 30 to 60 minutes, shorter than open approaches in select cases, though complex tunneled placements may extend this.^[36] Both techniques prioritize tube types based on anticipated duration: non-tunneled for temporary access with simple fixation, and Witzel-tunneled for long-term anti-reflux efficacy, as the tunnel functionally mimics a one-way valve.^[32] Site selection consistently avoids proximity to the duodenum to prevent reflux, with the 20- to 40-cm distal positioning balancing accessibility and physiological flow.^[1]

Radiologic Techniques

Radiologic techniques for jejunostomy involve image-guided percutaneous placement of feeding tubes directly into the jejunum, bypassing the need for endoscopic or surgical intervention. These methods primarily utilize fluoroscopy, ultrasound, or computed tomography (CT) to ensure precise access, making them suitable for patients with anatomical challenges that preclude other approaches.^[31] Direct percutaneous radiologic gastrojejunostomy (PRGJ) employs fluoroscopy or CT guidance to access the jejunum via transgastric puncture. Under local anesthesia, the stomach is first distended with air or contrast via a nasogastric tube for visualization, followed by needle puncture through the abdominal wall into the stomach and advancement into the proximal jejunum. Contrast injection confirms intraluminal positioning, after which serial dilations enlarge the tract, allowing deployment of a 10-16 Fr locking-loop or balloon-retained tube.^[37]^[38] The transjejunal approach targets the jejunum directly, often using ultrasound or fluoroscopy, particularly in intensive care unit (ICU) settings for bedside procedures in critically ill patients. A loop of jejunum is identified and distended with saline or air through a nasojejunal tube; ultrasound facilitates puncture by visualizing peristalsis and avoiding vessels, while fluoroscopy aids in guidewire advancement. The tract is serially dilated, and a pigtail or Cope loop catheter is inserted and secured.^[31]^[20]^[39] These radiologic methods are indicated for patients unable to undergo endoscopy, such as those with esophageal obstruction, upper gastrointestinal stenosis, or prior gastric surgery that limits scope passage.00850-5/fulltext)^[20] Unlike endoscopic techniques, which rely on direct visualization via scopes, radiologic approaches use imaging alone for guidance.^[40] Technical success rates for radiologic jejunostomy range from 92% to 100%, with procedural times typically 20-60 minutes depending on patient anatomy and imaging modality.^[41]^[20]^[37]

Procedure Details

Preoperative Preparation

Preoperative preparation for jejunostomy placement begins with a thorough patient assessment to evaluate suitability and minimize risks. Nutritional status is evaluated through laboratory tests, including serum albumin levels, as low preoperative albumin (typically <3.5 g/dL) is associated with increased postoperative complications and is a predictor of outcomes in patients requiring enteral feeding.^[42] Coagulation profile, including prothrombin time (PT) and international normalized ratio (INR), must be assessed, with severe coagulopathy (INR >1.5, aPTT >50 seconds, or platelets <50,000/mm³) considered a relative contraindication to the procedure.^[1] Preoperative imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), is performed to delineate anatomy, particularly in cases of altered gastrointestinal structure or to assess for potential obstacles like adhesions.^[1] Informed consent is obtained after comprehensive counseling on the procedure's risks (e.g., infection, bleeding, tube dislodgement), benefits (e.g., long-term enteral access for nutrition), and alternatives such as temporary nasojejunostomy tubes or parenteral nutrition.^[1] This discussion ensures patient understanding and aligns with indications like gastrointestinal obstruction or prolonged recovery needs. Bowel preparation involves antibiotic prophylaxis according to institutional guidelines to reduce infection risk, along with nil per os (NPO) status for at least 6 hours preoperatively to minimize aspiration during the procedure.^[1] Clear fluids may be permitted up to 2 hours prior in select cases, per enhanced recovery protocols.^[43] Anesthesia planning is tailored to the technique: general anesthesia is standard for open or laparoscopic surgical approaches, while moderate sedation suffices for endoscopic or radiologic methods.^[1] Multidisciplinary input is essential, involving gastroenterologists for procedural oversight and nutritionists to select appropriate enteral formulas based on patient needs, such as caloric density and tolerance.^[44] This collaborative approach optimizes preparation and supports long-term nutritional management.^[45]

Intraoperative Steps

The intraoperative phase of jejunostomy placement begins with establishing access to the peritoneal cavity or jejunum, tailored to the chosen technique. In open surgical approaches, a midline supraumbilical incision is made to expose the abdominal contents, allowing direct visualization.^[46] For laparoscopic methods, pneumoperitoneum is created using a Veress needle at the umbilicus with CO₂ insufflation to 15 mm Hg, followed by placement of ports: typically a 5- to 10-mm camera port to the right of the umbilicus and additional 5-mm working ports in the right abdomen.^[47] Percutaneous techniques, such as radiologic or endoscopic guidance, involve initial needle puncture through the abdominal wall into the jejunum under imaging, often using a trocar after transillumination or fluoroscopy to confirm position.^[1] Next, the jejunum is identified and mobilized to select an optimal loop, ensuring no tension on the mesentery to prevent ischemia or displacement. The ligament of Treitz is located, and a loop 20-40 cm distal is chosen, typically 30 cm from the duodenojejunal flexure, brought anteriorly to the abdominal wall without kinking.^[46] In laparoscopic procedures, the patient is positioned in reverse Trendelenburg with the left side elevated for better exposure, and the loop is anchored temporarily if needed.^[48] Mobilization avoids excessive traction, with the selected site marked to align with the planned exit point in the left upper quadrant, at least 4 cm from the costal margin.^[47] Stoma creation follows, involving incision of the jejunal wall and tube insertion with secure fixation. A small enterotomy is made on the antimesenteric border, and a 12- to 14-Fr feeding tube is advanced 30 cm into the jejunum, secured initially with a purse-string suture of 3-0 polyglactin to prevent leakage.^[1] A serosal tunnel, approximately 5 cm long, is formed using interrupted Lambert or seromuscular sutures to encase the tube, reducing reflux risk, particularly in Witzel techniques.^[46] Fixation to the abdominal wall employs 3-4 seromuscular sutures in a three-point configuration or tacks for laparoscopic cases, with balloon-retained tubes inflated post-insertion for additional stability in percutaneous methods.^[47] Verification ensures correct positioning and integrity. The tube is flushed with saline to confirm patency and free flow, followed by injection of water-soluble contrast under fluoroscopy or via a flat-plate abdominal X-ray to assess intraluminal placement, absence of leaks, and no extravasation into the peritoneum.^[36] Laparoscopic visualization provides real-time confirmation in minimally invasive approaches.^[47] Closure completes the procedure, with approximation of the abdominal wall layers using absorbable sutures in open techniques; drains are placed selectively if concern for fluid accumulation exists.^[1] In laparoscopic and percutaneous methods, port sites are closed with subcuticular sutures, and the tube is externally secured to the skin. Throughout, strict aseptic technique is maintained, with continuous hemodynamic monitoring under general anesthesia to track vital signs and prevent complications like hypotension.^[46]

Postoperative Care

Following jejunostomy placement, patients undergo close monitoring of vital signs, including blood pressure, heart rate, and temperature, to detect early signs of hemodynamic instability or infection. The surgical site is inspected regularly for bleeding, erythema, swelling, or drainage, with initial nil-by-mouth status maintained to promote gastrointestinal rest.^[2] Enteral feeding initiation typically begins within 24 hours postoperatively, starting with a sterile water flush (e.g., 30 mL for adults) to confirm patency, followed by low-volume continuous feeds via pump if no immediate complications arise. Feed rates are titrated gradually, often beginning at 10-20 mL/hour and advancing over 2-3 days to goal volumes, using polymeric formulas to minimize risks like dumping syndrome; bolus feeding is generally avoided in the jejunum.^[43]^[1]^[49] Pain management involves multimodal analgesia, including opioids, nonsteroidal anti-inflammatory drugs, and local anesthetics as appropriate, alongside antiemetics to control nausea. Early ambulation is encouraged, typically within 12-24 hours postoperatively, to prevent deep vein thrombosis and promote bowel function recovery.^[50]^[34] Follow-up care includes radiographic imaging, such as abdominal X-ray, if tube dislodgement is suspected based on output changes or patient symptoms. Discharge criteria generally require stable tolerance of enteral feeds at target rates, absence of acute complications, and evidence of site healing, often within 3-7 days depending on the procedure type and patient status.^[1]

Complications

Mechanical Complications

Mechanical complications of jejunostomy tubes primarily involve physical disruptions to the device's placement, integrity, or function, often arising from patient movement, improper securing, or material degradation. These issues can lead to feeding interruptions, requiring prompt intervention to restore nutrition delivery. Common mechanical problems include tube dislodgement, clogging, leakage or perforation, migration, and buried bumper syndrome, with overall complication rates ranging from 10% to 44% depending on the placement technique and patient population.^[51]^[52] Tube dislodgement is one of the most frequent mechanical issues, occurring in approximately 10-20% of cases, with higher rates observed in mobile or active patients due to traction from physical activity or accidental pulls. Early dislodgement, typically within the first two weeks post-placement, often results from inadequate initial fixation or patient inadvertence, while late dislodgement may stem from tube wear or loosening of sutures. In a large cohort study of 542 patients, dislodgement affected 12% of jejunostomy tubes, frequently necessitating replacement.^[51]^[53]^[54] Clogging of the jejunostomy tube arises from the accumulation of viscous enteral formulas, undissolved medications, or formula residues within the narrow lumen, particularly in smaller-bore tubes. This complication is reported in 6-13% of cases and can interrupt feeding, leading to undernutrition if not addressed. Prevention strategies emphasize regular flushing with 30-60 mL of warm water before and after each use, as well as crushing and dissolving medications adequately to minimize particulate buildup.^[52]^[51]^[55] Leakage or perforation at the tube site results from poor initial fixation, erosion of the jejunal wall due to constant pressure from the tube tip, or degradation of the stoma tract over time. Leakage, noted in about 5% of patients, often manifests as seepage of enteric contents around the exit site, causing skin irritation, while perforation represents a more severe issue with risks of peritonitis if intraperitoneal spillage occurs. In one series, skin site leaks affected 6 out of 117 patients with gastroesophageal cancer, frequently linked to anchor suture failure. Perforations are rarer but can arise from localized pressure necrosis, as seen in cases where the tube tip erodes through the bowel wall.^[52]^[56] Migration of the jejunostomy tube involves unintended movement, either retraction proximally toward the stomach or advancement distally into the peritoneum or further bowel segments, potentially causing obstruction or leakage. Proximal migration, often due to peristalsis or inadequate anchoring, occurs in up to 6% of cases and may lead to reflux of feeds. Distal advancement or enteral migration is less common but can result from balloon deflation or tube breakage, with reports of spontaneous antegrade movement requiring non-operative management in stable patients.^[1]^[57] Buried bumper syndrome, though less common in jejunostomy than gastrostomy tubes, develops from over-tightening of the external bumper, leading to ischemic necrosis and mucosal overgrowth that embeds the internal bumper into the jejunal wall. This rare complication, with an incidence of 1.5-1.9% in percutaneous endoscopic jejunostomy procedures, impedes tube advancement and feeding, often necessitating endoscopic release or replacement. It typically presents months after placement and is prevented by ensuring 1-2 cm of tube mobility at the stoma site during initial securing.^[58]^[59]

Infectious and Metabolic Complications

Infectious complications associated with jejunostomy primarily involve local site infections at the stoma or insertion point, manifesting as cellulitis or abscess formation. These infections occur in approximately 4-5% of cases, though rates can reach up to 10% in patients with predisposing factors such as diabetes, which impairs immune response and wound healing.^[60]^[61] Systemic infections, such as sepsis arising from peritonitis, are less common but more severe, with reported rates of serious abdominal septic complications around 1-2% following jejunostomy placement.^[62] Peritonitis can progress to sepsis if bacterial translocation occurs, often triggered by contamination during tube insertion or maintenance.^[63] Metabolic complications stem from the physiological demands of enteral feeding via the jejunostomy, including hyperglycemia due to rapid carbohydrate absorption and insulin resistance, observed in about 29% of patients. Electrolyte imbalances, such as hypokalemia (affecting up to 50% of cases) and hypophosphatemia, result from shifts during refeeding or high-volume infusions, potentially leading to muscle weakness or respiratory issues if severe. Dehydration is a frequent concern in jejunostomy feeding, often due to osmotic diarrhea or inadequate fluid supplementation with enteral formulas, leading to fluid and sodium depletion in 1-17% of patients, exacerbated by inadequate hydration volume.^[64]^[65]^[66] Prevention of infectious complications relies on perioperative antibiotic prophylaxis, such as cefazolin or equivalent broad-spectrum agents administered per institutional guidelines, which significantly reduces site infection risk. Strict sterile technique during insertion and site care, including skin disinfection and use of sterile dressings, further minimizes contamination. For metabolic issues, monitoring serum glucose, electrolytes, and fluid balance with gradual feed initiation helps mitigate hyperglycemia, imbalances, and dehydration. Tube dislodgement may occasionally contribute to infection entry but is managed separately.^[1]^[67]^[68]

Gastrointestinal Complications

Gastrointestinal complications associated with jejunostomy primarily arise from the anatomical and physiological characteristics of the jejunum, which lacks the reservoir function of the stomach and has limited adaptation to hyperosmolar feeds, leading to issues such as reflux, rapid transit, and local ischemia. These adverse effects can occur despite the post-pyloric placement intended to minimize gastric-related problems, affecting patient tolerance and nutritional delivery. Common manifestations include aspiration events, diarrheal syndromes, obstructive phenomena from luminal contents, fistulous communications, and ischemic tissue damage, with overall gastrointestinal complication rates reported in up to 30% of cases in some cohorts.^[69] Aspiration pneumonia remains a significant risk even with jejunal feeding, as feedings can reflux into the stomach or esophagus due to gastroesophageal incompetence or delayed gastric emptying, with incidence rates ranging from 6% to 16% across studies. In one retrospective analysis of 112 patients undergoing Witzel jejunostomy, aspiration pneumonia occurred in 6.25% of cases, highlighting its persistence as a medical complication unrelated to tube position alone. Similarly, a review of 44 nursing facility patients showed a 15.9% incidence, rising to 31.6% in those with prior aspiration history, underscoring that jejunostomy does not fully protect against this event. While some early studies suggested no significant reduction in aspiration or pneumonia rates compared to gastric feeding, more recent meta-analyses indicate a modest reduction with post-pyloric (jejunal) feeding (RR 0.70-0.75), though evidence quality is low and vigilant monitoring such as head-of-bed elevation remains essential.^[69]^[54]^[70]^[71]^[72] Diarrhea and dumping syndrome frequently complicate jejunostomy due to the jejunum's limited capacity to buffer osmotic loads from unadapted enteral formulas, resulting in rapid transit and fluid shifts that manifest as loose stools, abdominal cramping, nausea, and hypoglycemia. Diarrhea affects up to 30% of enterally fed patients, often multifactorial but exacerbated by hyperosmolar feeds in the jejunum, which bypasses gastric mixing and dilution. Dumping syndrome, characterized by early vasomotor symptoms and late reactive hypoglycemia, has been documented in case series of post-surgical patients with jejunostomy, particularly in esophageal cancer cases where altered anatomy promotes rapid emptying. Management involves gradual feed initiation and iso-osmolar formulas to mitigate these osmotic effects.^[73]^[74]^[75] Intestinal obstruction from bezoar formation represents a rarer but serious gastrointestinal issue, where undigested formula residues or fiber aggregates into masses within the jejunum, potentially leading to partial or complete blockage due to the site's narrowed lumen post-procedure. Bezoars account for 2-3% of small bowel obstructions overall and are particularly noted in patients with altered motility after jejunostomy, as seen in postoperative cases following gastric bypass or esophagectomy. These concretions form from inadequate formula breakdown and can present with acute pain and distension, requiring endoscopic or surgical intervention.^[76] Fistula formation, specifically enterocutaneous fistulas, arises from incomplete tract closure after jejunostomy tube removal, resulting in persistent leaks of enteric contents through the abdominal wall and complicating wound healing. Incidence of persistent fistulas post-jejunostomy reaches 3.7-8% in some series, often linked to prolonged tube dwell time exceeding 12 months or small tract diameters less than 15 mm. These leaks contribute to fluid and electrolyte losses, with one brief overlap to metabolic derangements such as hypokalemia from diarrheal output.^[77] Jejunal necrosis due to ischemia at the fixation site is a grave complication, stemming from compromised mesenteric perfusion during tube placement or early feeding, which elevates local pressure and disrupts vascular supply in the fixed bowel segment. This rare event, with reported rates of 0.1-3.5% in enteral feeding cohorts, carries high morbidity and mortality up to 100% if undetected, as evidenced by case series of postoperative patients developing full-thickness necrosis 3-15 days after initiation. Risk factors include vasopressor use and major abdominal surgery, necessitating prompt cessation of feeds and imaging upon suspicion of abdominal distension or pain.^[74]^[78]

Management and Outcomes

Tube Maintenance

Proper maintenance of a jejunostomy tube is essential for preventing complications such as clogging, infection, and dislodgement, ensuring long-term functionality in home or outpatient settings. Caregivers should receive training from healthcare providers on these protocols, with regular follow-up to monitor adherence and address any issues.^[79] Daily flushing is a critical practice to maintain tube patency and prevent occlusions from formula residues or medications. Tubes should be flushed with at least 30 mL of water before and after each feeding or medication administration, using a push-pause technique for effectiveness; for continuous feedings, flushes of 30 mL are recommended every 4 hours. In adults, 30-60 mL of lukewarm water or sterile water (for at-risk patients) is typically used after intermittent feeds or medications to clear the lumen adequately.^[79]^[80]^[2] Site care involves gentle cleaning to promote healing and prevent peristomal complications. The skin around the tube insertion site should be cleaned daily or 1-3 times per day with mild soap and warm water using a soft cloth or cotton swab, followed by thorough drying to avoid moisture-related irritation; avoid scrubbing to prevent skin breakdown. Monitor the site daily for signs of infection, such as redness, swelling, odor, or pus, and apply protective barriers like zinc oxide if leakage occurs; tube rotation is generally not recommended unless specified by a provider to avoid granulation tissue formation. Dressings should be changed daily or when soiled, using gauze and tape for securement.^[79]^[2]^[81] Feeding protocols for jejunostomy tubes prioritize methods that minimize gastrointestinal intolerance due to the small bowel's limited capacity. Continuous infusion via pump is preferred over bolus feeding, starting at 10-40 mL/hour and advancing by 10-20 mL/hour every 8-12 hours as tolerated, to reduce risks like dumping syndrome. Bolus feeds, if used, should deliver 200-400 mL over 15-60 minutes, 4-6 times daily, but only under medical supervision. Formula selection should consider osmolarity, with isotonic or low-osmolarity options (typically 300-500 mOsm/L) to improve tolerance in the jejunum; high-osmolarity formulas require slower infusion rates.^[79]^[80] Tube replacement is necessary periodically or upon damage to ensure safety and efficacy. Balloon-type jejunostomy tubes should be checked weekly for balloon integrity and replaced every 3-6 months, or sooner if clogged, leaking, or dislodged; direct percutaneous jejunostomy tubes may last longer, with replacement intervals up to 5 months in some cases. Replacement procedures vary: low-profile devices can often be exchanged non-surgically if the tract is mature (after 4 weeks), while others require endoscopic or interventional radiology guidance; surgical intervention is reserved for complex cases.^[79]^[82] Troubleshooting involves prompt recognition and management of common issues to avoid escalation. Signs of problems include tube clogging (resistance during flushing), leakage around the site, persistent pain, or changes in feeding tolerance such as bloating or nausea; attempt unclogging with warm water flushes (up to 30 mL in 5-10 mL increments) before seeking help, but avoid enzymatic agents without provider approval due to limited evidence. Caregivers should contact a healthcare provider immediately for unresolved clogs, signs of infection (fever, increased redness), accidental dislodgement (secure temporarily with tape and seek urgent replacement, as the tract can close quickly), or any bleeding; emergency care is warranted if severe symptoms like vomiting or abdominal distension occur.^[79]^[2]^[81]

Long-Term Outcomes

Jejunostomy feeding demonstrates high efficacy in delivering enteral nutrition, with success rates ranging from 80% to 90% in achieving adequate caloric intake and supporting weight maintenance or gain in malnourished patients, particularly those undergoing esophageal or gastric cancer surgery.^[83] In one cohort of patients receiving direct percutaneous endoscopic jejunostomy, 90% experienced effective nutrition delivery, accompanied by evidence of weight gain or stabilization over long-term follow-up.^[83] Modern techniques, such as percutaneous or laparoscopic placement, contribute to these outcomes by minimizing procedural risks, with major complication rates below 15% in contemporary series.^[51] Regarding survival benefits, jejunostomy placement in cancer patients is associated with improved overall and progression-free survival in select populations, potentially extending median survival by several months compared to cases without enteral access, alongside reductions in hospital readmissions due to better nutritional support.^[84] For instance, routine feeding jejunostomy during esophagectomy has shown higher 5-year survival rates and decreased 180-day mortality, though results vary by tumor stage and palliative versus curative intent.^[84]^[85] Quality of life following jejunostomy is generally enhanced through greater patient independence relative to total parenteral nutrition, as enteral feeding supports home management, reduces infection risks, and improves functional status without the mobility limitations of intravenous lines.^[86] Studies indicate benefits in global health-related quality of life, including reduced pain and better role functioning, though visible tube presence can lead to body image concerns and social interference in some cases.^[87]^[88] Tube removal occurs upon recovery of sufficient oral intake, often within months post-procedure, allowing discontinuation in patients with improved swallowing function after cancer treatment or rehabilitation. In one evaluation of jejunostomy outcomes, approximately 31% of surviving patients had their tubes discontinued after tolerating oral intake.^[89] This reflects successful nutritional rehabilitation, with lower long-term dependence enabled by advances in multidisciplinary care.

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None
Summary of each segment:
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