Editing Jejunostomy

== '''Contraindications''' ==

* Infected overlying skin
* Severe ascites
* Peritonitis
* Severe coagulopathy
* Haemodynamic instability

== '''Open technique''' ==

* Identify jejunum 40-60cm distal to ligament of Treitz, and mark distal and proximal ends
* Double-layer purse-string with 3/0 PDS, leaving needles on both. Orient one proximal and one distal for subsequent suturing to peritoneum
* Enterotomy with diathermy
* Pass feeding tube through abdominal wall and into jejunum (flushing some water through can help get it distally into jejunum)
* Inflate balloon as per instructions
* Tie purse-strings, first around the tube, then suture to peritoneum
* Add a single suture 2cm distal to jejunostomy to prevent torsion

== '''Hybrid open/lap''' ==

* Cut down from skin 2cm superior to desired site
* Externalise bowel with Babcock's
* Purse-string with 3/0 PDS, finishing one inferior corner
* Second purse-string, finishing other inferior corner
* Diathermy cutdown for tube, inferior to open cut, and pass tube through it
* Tube into bowel in centre of purse-strings, and inflate balloon as per instructions
* Use purse-strings to secure to peritoneum at two points
* Place two interrupted sutures at superior corners
* Anti-torsion suture 5cm proximal
* Leak test

== '''Laparoscopic technique''' ==

* Camera port and two hand ports in upper abdomen
* 50cm distal to DJ flexure; mark proximal and distal directions
* Do the two posterior quadrant sutures to peritoneum so bowel is hitched up. Easiest thing to do is use trans-fascial suture passer and then clip the sutures externally to allow the bowel to be manipulated.
* Suture with absorbable v-lok in a purse-string, starting front-right and moving anti-clockwise, so knot will be in the front. Don't tie yet.
* Pass the feeding tube into abdomen; make the hole; pass the tube in and inflate balloon
* Tie the purse-string suture
* Do the two anterior quadrant sutures
* Do anti-torsion sutures 5-10cm proximally and distally
* Leak test with water, check to ensure balloon is not over-inflated causing obstruction
* Close

== '''Alternative techniques:''' ==

* Witzel tunnel

== '''Post-op:''' ==

* Commence water flushes immediately
* Dietician review
* Feeds can be started same day

== '''Complications''' ==

* Pain
* Leak
* Clogged tube
* Dislodgement
** <4 weeks: can try gently sliding another tube (initially a Foley, followed by a jejunostomy when available) through the fistula, followed by a tubogram before use to exclude leak. If any resistance or doubt, abort and will need repeat surgical insertion. 
** >4 weeks: replace and send for tubogram before use
* Obstruction
** Generally caused by over-inflation of balloon - deflation is both diagnostic and therapeutic
* Infectious
** Aspiration pneumonia - tube too proximal - continuous feeds while sleeping can worsen
* Gastrointestinal
** Nausea/vomiting
** Diarrhoea
** Distension
* Metabolic
** B12/iron deficiencies
** Hypokalaemia, hyperglycaemia and acid-base disturbances



[[Category:Small bowel]]