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