Digestive Surgery
Original Paper
Relaparotomy following Complications of Feeding Jejunostomy in Esophageal SurgeryHan-Geurts I.J.M. · Verhoef C. · Tilanus H.W.Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Article / Publication Details
Received: August 25, 2003
Accepted: February 11, 2004
Published online: July 28, 2004
Issue release date: July 2004
Number of Print Pages: 5
Number of Figures: 0
Number of Tables: 5
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
Abstract
Background: After recognition of the importance of early postoperative enteral feeding, placement of a feeding jejunostomy as an adjunct to gastrointestinal surgery has become widely accepted. However, little attention has been paid to surgical complications and their consequences. Feeding jejunostomy as an adjunct to esophageal resection and reconstruction can lead to serious surgical complications. Methods: Between 1978 and 2000, 1,387 patients underwent esophageal resection and reconstruction. Of these, 1,166 patients received a needle catheter feeding jejunostomy at the end of the operation. All postoperative complications were prospectively evaluated in a database including surgical complications related to the feeding jejunostomy. Results: Overall, surgical complications occurred in 36%. There were 13 (1.1%) feeding jejunostomy related complications leading to relaparotomy. Of these, intraperitoneal leakage was the most common complication (n = 5). Other jejunostomy-related complications included dislodgement (n = 4), herniation (n = 3) and torsion (n = 1). Five patients (0.4%) died despite relaparotomy. Conclusions: Feeding jejunostomy as an adjunct to esophageal resection and reconstruction can lead to serious surgical complications. Preventive measures have not resulted in a decrease in complication rate. Complications of leakage necessitating relaparotomy are associated with a high mortality rate. Therefore, other means of enteral access should be considered.
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Article / Publication Details
Received: August 25, 2003
Accepted: February 11, 2004
Published online: July 28, 2004
Issue release date: July 2004
Number of Print Pages: 5
Number of Figures: 0
Number of Tables: 5
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
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PubMed IDRichard D. Page
The Cardiothoracic Centre, Liverpool, UK
I like papers that look at surgical complications. From a practical surgical standpoint I think there is much more to learn than from a description of a series of procedures with zero morbidity. Han-Geurts and colleagues are to be congratulated on their honest presentation of one of the largest experiences with routine postoperative jejunostomy feeding after esophagectomy, with a small but finite risk of major jejunostomy-related morbidity and mortality. This complication rate is very much in line with others who use the technique as a routine and have experienced similar problems of catheter dislodgement and peritonitis, herniation, intestinal obstruction etc. Lesser problems such as blockage of the tube, failure of the infusion pump, diarrhea, etc. are presumably more common, although much less serious for their patients.
Although the authors have suggested further work to compare jejunostomy with nasoduodenal tube feeding, I think this is less important than a discussion of the place of routine enteral feeding after any major elective surgery. Although intuitively beneficial in terms of preventing morbidity in nutritionally challenged patients such as those undergoing an esophagectomy (where nutritionally useful oral intake cannot be resumed for at least a week until anastomotic healing has occurred), no major benefit has ever been shown from routine enteral support. This is quite a different situation from the septic patient who has developed complications for whom enteral nutrition is entirely appropriate. Most esophageal surgeons who insert a jejunostomy catheter at the end of every esophageal resection do so in the knowledge that the technique is really used as a ‘safety net’ for those patients who go on to develop major complications, especially anastomotic leakage. Taking this argument further it could be argued that for the majority who do not develop these complications, insertion of the jejunostomy catheter will turn out (in retrospect) to be an unnecessary procedure. The real question then is whether addition of this invasive procedure with a risk of 1% for major morbidity is justified for all patients, for whom only a small minority will the procedure turn out to be justified.
All surgeons are heavily influenced by their training and personal experience when they choose various surgical techniques, many of which show comparable results when subjected to scientific scrutiny, although it is always extremely difficult to construct a trial which can show differences between two surgical procedures. By far the best practical approach for surgeons is to remain flexible about their chosen techniques so that operations are adapted to individual patient requirements, rather than following a rigid routine. With respect to enteral feeding in post-esophagectomy patients there is the option of prophylactic peri-operative jejunostomy insertion for those thought to be at high risk of anastomotic leakage, and in the remainder avoiding enteral feeding routinely, reserving the technique for the post-operative period for those patients who do turn out to need it because of complications.
