Feeding Jejunostomy

Jejunostomy feeding tube

A jejunostomy tube (J-tube) is a feeding tube inserted directly into the jejunum (the second part of the small intestine) to give nutrition, fluids, and medication when a person is unable to eat or digest food safely because of the stomach. 

What is a Jejunostomy?

A jejunostomy is an opening made through the abdominal wall into the jejunum either surgically or with an endoscope. This hole is passed through a feeding tube through which direct intestinal feeding is done bypassing the stomach.

What Are the Uses of a Jejunostomy Feeding Tube?

Use of a J-tube is indicated when stomach feeding is not possible   or safe, for instance in:

• In advanced swallowing disorders.
• Obstruction or cancer of the esophagus.
• Gastric outlet obstruction 
• Aspiratory severe gastroesophageal reflux.
• Upon big upper GI surgery (esophagus or stomach)
• Pancreatitis (in case of aggravation of symptoms by gastric feeding)
• Food related neurological conditions.

Types Of Jejunostomy Feeding Tube

Surgical Jejunostomy 

• Laparoscopic surgery or open surgery.
• Essentially employed in big abdominal surgery.

PEJ

• Placed using an endoscope
• Not as invasive as open surgery.

PEG-J Tube

• And jejunal extension was performed through an existing gastrostomy tube.

Laparoscopic feeding jejunostomy

Laparoscopic feeding jejunostomy is an invasive technique to place the feeding tube directly in the jejunum with help of laparoscopic instruments (miniature camera and a few small size ports for instruments), instead of performing the open surgery. This is generally performed in patients who cannot eat by mouth or who cannot be fed safely through the stomach. 

Indications

Laparoscopic jejunostomy occurs in cases where:

• These patients suffer from upper type gastrointestinal obstruction (esophagus, stomach).
• Severe dysphagia (difficulty in swallowing)
• Aspiration is a risk with gastric feeding. 
• Post major upper GI (esophagectomy, gastrectomy) surgery.
• Jejunal feeding due to chronic pancreatitis.
• Oral intake impairment due to neurological disorders.

The benefits of Laparoscopic Approach

Laparoscopy has; compared to open surgical jejunostomy:

• The smaller incisions result in less pain and a faster recovery.
• Lower risk of wound infection. 
• Shorter hospital stay
• Premature restoration of normal life.
• More effective imaging of bowel and adjacent structures.

Procedure Overview

• Anaesthesia: The patient is given general anaesthesia.
• Locations of Ports: The size of the incisions through the abdomen is 2-4 small keyholes (5-10 mm).
• Bowel recognition: The jejunum (ordinarily 20-30 cm above the ligament of Treitz) is located.
• Fixation of the jejunum: The jejunum is sutured to the abdominal wall to prevent mobility.
• Tube insertion: A tube is inserted into the abdomen into the jejunum. 
• Finally, the tube can be closed, ports are excised, and small incisions are sutured.
• Confirmation Tube placement is at times confirmed by X-ray or fluoroscopy.
• Operating Time: 30–60 minutes.

Jejunostomy tube placement

This tube is introduced into the jejunum (mid-point of the small intestine) to deliver nutrition in case of oral or stomach intubation being unachievable. Placement may be either surgical, laparoscopic or endoscopic.

Indications

A J-tube is indicated when:

• Oral feeding (such as in the case of swallowing disorders) is not safe.
• Gastric feeding is not possible or is unsafe (risk of aspiration, gastric obstruction)
• After upper GI surgery (esophagectomy, gastrectomy).
• Severe malnutrition or haemolytic anaemia.
• Feeding the neurologically impaired.

Methods of Placement

Surgical Jejunostomy

• Open surgery
• A tube is passed down the jejunum and fixed to the wall of the abdomen.
• It can be used in other abdominal surgeries as well.

Laparoscopic Jejunostomy

• Minimal invasive keyhole surgery.
• It uses tiny incisions and a camera.
• Benefits include less pain, quicker healing time, and smaller scar.

Percutaneous Endoscopic Jejunostomy 

• Endoscopically, tube is inserted through the abdominal wall. 
• Frequently by means of a preexisting gastrostomy (PEG-J).
• Less invasive, applicable to patients, who are not in surgery

Feeding jejunostomy procedure

A feeding jejunostomy is a feeding tube inserted through the skin of the abdomen into the jejunum to provide enteral nutrition when feeding by mouth or through a stomach tube is not possible. It can be done open, laparoscopically or endoscopically.

Preoperative Preparation

• Patient evaluation: Nutritional status, abdominal configuration, and comorbidities.
• Consent: Explain procedure, risks, benefits and alternatives.
• Nothing by mouth: The patient is generally NPO (nothing by mouth) for 6 to 8 hours.
• Antibiotics: Prophylaxis: Can be given IV antibiotics.
• Anaesthesia: General anaesthesia most often; local sedation.

Approaches for Jejunostomy 

Open Surgical Jejunostomy

• There is a minor cut in the abdomen.
• The jejunum is recognized and tugged at, towards the abdominal wall.
• The tube is placed and fastened using sutures.

Laparoscopic Jejunostomy

• Small keyhole openings are made 2 to 4.
• The jejunum is identified with the help of a camera and instruments.
• The jejunum is attached to the wall of the abdomen.
• The feeding tube is inserted laparoscopically. 

PEJ

• Frequently through an already-in-place gastrostomy (PEG-J tube).
• The tube is inserted in urethra endoscopically into jejunum.

Procedure

The first step is called Access and Visualization.

• Abdomen is sponged and covered.
• The jejunum is located (typically 2030cm below the ligament of Treitz).

Step 2: Fixation

• A part of the jejunum is pushed to the abdominal wall.
• Sutures are also introduced to fix the bowel (seromuscular fixation).

Step 3: Tube Insertion

• A little enterotomy (hole in the jejunum) is performed.
• The feeding tube is inserted through the abdominal wall into the jejunum.
• The tube is secured with sutures or a retention device (balloon or flange).

Step 4: Confirmation

• Proper positioning of the tube may be confirmed by contrast or aspirate of jejunal contents. 

Step 5: Closure

• The tube is surrounded with abdominal wall and skin incisions.
• Dressing is used in order to avoid infection.

Postoperative Care

• Feeding: This typically begins 24-48 hours of placement. Slow feeds are preferred to be continuous.
• Tube care: Wipe with water in between feeds/medications.
• Site care: Clean daily, observe redness, swelling and leakage.
• Follow up: Observe for abdominal pain, diarrhea, or tube obstruction.

Best hospital for feeding jejunostomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

A feeding jejunostomy is a safe, effective and frequently life-saving treatment to patients who cannot tolerate oral or gastric feeding. Because it goes to the jejunum directly, it provides adequate nutrition to the patient, enables healing, and reduces complications, including aspiration pneumonia. It is less invasive (with contemporary technique laparoscopic or endoscopic placement), requires fewer incisions and has faster recovery and the incidence of post-operative complications is less. Appropriate tube care and monitoring are required to prevent tubes from becoming obstructed or infected, and to ensure proper tube function. 

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FAQ

What is the earliest time to feed after placement?

• Feeding is initiated at 24–48 h postoperatively in most cases. Continuous slow feeding is the initial preference.

What can you put in a J-tube?

• Liquid enteral nutrition formulas
• Fluid as directed.
• Drugs (liquid or crushed and diluted, only if the doctor approves).
• You can't feed solid food.

Is a jejunostomy tube permanent?

• Not really. It may be temporary or permanent depending on the patient’s condition. Tubes can be replaced too.

Can you shower or swim with a J-tube?

• Yes, as soon as the site has healed. Be careful not to contaminate or water wet the wound).

How long does the cannula last?

• They are usually replaced every 3 to 12 months. It depends on the type of gånger-tube you have and also on how well you care for it. They can be replaced if necessary.