Complications of Feeding Complications of Feeding Jejunostomies
N. Dayes
King County Medical CenterKing County Medical Center
Trauma Service
ES 1961241
85 y.o. female nursing home resident.
Past Medical Hx – Afib, HTN, CVA
Admitted for 2nd acute embolic CVA with residual left h i i d h ihemiparesis and aphasia.
Referred to the GI service for PEG placement for enteral Referred to the GI service for PEG placement for enteral nutrition.
ES 1961241ES 1961241The patient suffered a gastric perforation during this procedure and a surgery consult was called.
WBC 8 85WBC – 8.85
H/H – 12.3/38
Plt 264Plt – 264
Na – 145, K – 3.5, Cl -106, bicarb – 23,
BUN/Cr – 22/0 63BUN/Cr 22/0.63
7.485/36.5/122/98/28/3.8
ES 1961241ES 1961241HOD # 10 -Taken to OR for exploratory laparotomy, gastric wedge resection, and feeding jejunostomy placement.
HOD# 11/POD #1 I b d N h HOD# 11/POD #1 – Intubated, Normotensive with a normal heart rate. Adequate urine output.
POD# 2 – Jejunostomy feeds were started.
ES 1961241ES 1961241POD#6 –
The patient became oliguric with a WBC 13. She was also hypotensive requiring pressor support.
Broad spectrum antibiotics were started . CVP and arterial line were placed for monitoring.
Abdominal exam revealed a soft, distended abdomen.
ES 1961241ES 1961241POD#6 –
Na – 146, K- 4.7, Cl – 115, Bicarb – 18, Glc – 79
BUN/Cr 46/1 71BUN/Cr – 46/1.71
7.232/38/110/97%/15.9/-10.5
Emergent abdomen/pelvis CT-scan ……….
ES 1961241ES 1961241POD#6 –
T k l h O f l l h h Taken emergently to the OR for exploratory laparotomy which revealed a displaced jejunostomy tube.
Previous jejunostomy site was closed in a two-layered fashion.
Enteral feeds noted throughout abdomenEnteral feeds noted throughout abdomen.
Copious irrigation
New feeding jejunostomy was placed distal to the old site.
ES 1961241ES 1961241HOD # 21/POD# 1 –WBC -10 , decreasing pressor support. Good urine output.
HOD#35 T h f d dHOD#35 -Tracheotomy for respiratory dependence.
HOD #50 Di h d t i h f ilitHOD #50 - Discharged to nursing home facility.
DiscussionDiscussionOptions for post-op enteral feeding.
Techniques for jejunostomy insertion.
Complications.
Is a jejunostomy a safe method?
Options for post op enteral feedingOptions for post-op enteral feedingNasogastric tube.
Gastrostomy.PEG ( d i )PEG (percutaneous endoscopic gastrostomy).Open.
Stamm.
Janeway.
Jejunostomy.Bush in 1858.
Surgical Jejunostomy in Aspiration Risk PatientsPatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992
Retrospective chart review of 100 patients from 5/1987 to 6/1990.
All were at risk for aspiration pneumonia.
All jejunostomies were performed by a single surgeon using a uniform techniqueuniform technique.
Major end-point was aspiration pneumonia Major end-point was aspiration pneumonia.
Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992Weltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992
Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992Weltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992
Analysis of this retrospective review reported an 8% incidence of postoperative aspiration pneumonia.
Compared to previously reported 23 to 40% incidence of aspiration pneumonia associated with percutaneous aspiration pneumonia associated with percutaneous gastrostomy tubes.1-2
1 Cogen R, Weinryb J. aspiration pneumonia in nursing home patients fed via gastrostomy tubes. Am J Gastro 1989; 84:1509-15122 Ci JO Sil t FA F l CJ T b f di i ld l ti t2 Ciocon JO, Silverstone FA, Foley CJ. Tube feedings in elderly patients. Arch intern Med 1988; 148:429-433.
T h i f j j t i tiTechniques for jejunostomy insertionLaparotomy
d l lLongitudinal Witzel
Transverse Witzel
Needle catheter
Percutaneous endoscopy gastrojejunostomy placementpy g j j y p
Laparoscopy
Complications Complications Mechanical
Intestinal occlusion
Intraperitoneal leakageIntraperitoneal leakage
Local abscess collection
Intestinal necrosis
[1] – Gerdt, SJ, Orringer, MB. Tube jejunostomy as and adjunct to esophagectomy, g j j y j p g ySurgery 115:164,1994
C li ti IIComplications II
InfectiousInfectiousAspiration Pneumonia
GastrointestinalAbdominal distention
Diarrhea
Constipation
Is a jejunostomy a safe method?Is a jejunostomy a safe method?Complications of Needle Catheter Jejunostomy in 2,022 Consecutive ApplicationsApplications.
Myer JG, Aust B, et.al. Amer J Surg 170:1995
Large retrospective review of patient charts from 1978 to 1994.
All jejunostomies were inserted by a staff physician using a All jejunostomies were inserted by a staff physician using a similar commercially available kit.
Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995
Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995
Complications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995
Concluded that jejunostomies are a safe and effective means of providing nutritional support.
E h h h l d d l l Emphasis on the mechanical aspects and radiological confirmation.
ConclusionConclusionPost –pyloric feeding is advantageous in patients with a high risk of aspiration.
A f d b d d f d ff A feeding jejunostomy can be considered safe and effective routes for enteral feeding.
While a safe approach, a feeding jejunostomy, as with all invasive procedures, is not risk free.p ,
ReferencesReferencesComplications of Needle Catheter Jejunostomy in 2,022 Consecutive Applications Myer JG Aust B et al Amer J Surg 170:1995Applications. Myer JG, Aust B, et.al. Amer J Surg 170:1995
Gerdt, SJ, Orringer, MB. Tube jejunostomy as and adjunct to esophagectomy, Surgery 115:164,1994.
S l A k Surgical Jejunostomy in Aspiration Risk PatientsWeltz CR, Morris JB, Mullen JL. Ann Surg 215:140,1992
Cogen R, Weinryb J. aspiration pneumonia in nursing home patients fed via bgastrostomy tubes. Am J Gastro 1989; 84:1509-1512
Ciocon JO, Silverstone FA, Foley CJ. Tube feedings in elderly patients. Arch intern Med 1988; 148:429-433.
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