BACKGROUND: Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.
METHODS: This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.
RESULTS: In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).
CONCLUSIONS: Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Intestinal obstruction is a common surgical emergency that can be caused by mechanical causes or by different pathological processes. The most common cause of small bowel intestinal obstruction is post-operative adhesion, and the most common cause of large bowel obstruction is malignancy. These are classified into dynamic and adynamic types. The patient was selected based on the presentation management plan. Some cases require immediate operative intervention; however, some cases, as mentioned in this case series, require further investigation and a different approach. In this study, we report the rare causes of intestinal obstruction presented to Safdarjung Hospital, Department of General Surgery, New Delhi: one case of foreign body impaction, one case of spontaneous migration of feeding jejunostomy, one case of extrauterine IUCD causing intestinal obstruction, one case of mesentery band causing obstruction, and one case of abdominopelvic mass causing small bowel obstruction. These cases presented to the surgical emergency department with challenges in their diagnosis, intraoperative findings, and their outcomes.

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UNASSIGNED: Early oral feeding after major abdominal surgery has been clearly shown to be safe and not a risk factor for anastomotic dehiscence. Within the Enhanced Recovery after Surgery protocol, it is the nutritional plan A. Nonetheless, one must consider that postoperative protein and energy requirements will often be not covered by oral food intake alone. Because nutritional status has been shown to be a prognostic factor in patients undergoing major abdominal surgery, the preoperative identification of patients at risk may be mandatory. Malnutrition may be underestimated in an overweight society. With special regard to patients with cancer and those with preexisting malnutrition, an accumulating caloric gap may be harmful in the early and late postoperative periods. Furthermore, complications requiring reoperation and intensive care treatment may occur.
UNASSIGNED: Therefore, a plan B for postoperative nutrition therapy is needed, using preferentially the enteral route. The European Society for Clinical Nutrition and Metabolism recently addressed perioperative nutritional management and the indications for enteral and even parenteral supplementation to achieve caloric requirements in the postoperative course. In the first months after surgery, persisting weight loss is common in patients with upper gastrointestinal resections, even in those with an uncomplicated course. This may delay the initiation of adjuvant chemotherapy, increase toxicity, and worsen long-term outcomes.

Duodenal trauma resulting in perforation is rare and management can be challenging due to injuries in other organs and vascular structures. Primary repair is the preferred option and is technically feasible even in cases with large defects. In more complex injuries with pancreaticobiliary tract involvement, damage control techniques and staged procedures may be required. Triple tube drainage with tube gastrostomy, tube duodenostomy, and feeding jejunostomy can benefit the adequate decompression of the duodenum and protect the primary repair suture line. We report the case of a 35-year-old male patient with perforation in the second part of the duodenum following a gunshot injury, who was managed with primary repair and triple tube drainage.

UNASSIGNED: Feeding jejunostomy (FJ) is one of the frequently performed surgical procedures for enteral nutrition, but intussusception a very rare complication with quite challenging clinical outcome. It symbolizes a surgical emergency requiring prompt diagnosis.
UNASSIGNED: Feeding jejunostomy (FJ) is a minor surgical intervention, which might lead to consequences that are potentially fatal. Mechanical issues such as infection, tube dislocation or migration, electrolyte and fluid imbalances, as well as complaints of gastrointestinal tract, are the most frequent consequences. A 76-year-old female, who is a known case of carcinoma (CA) esophagus: Stage 4 with Eastern Cooperative Oncology Group (ECOG) Class 3 presented with complaints of difficulty in swallowing and vomiting. As a part of palliative treatment, FJ is done and patient was discharged on postoperative day (POD) 2. Patient again presented to emergency department after 2 months with complaints of pain abdomen, unable to pass flatus and stools for 2 days. Contrast-enhanced computed tomography was done, which revealed intussusception of jejunum with lead point as tip of feeding tube. Intussusception of jejunal loops is noted 20 centimeters distal to the site of insertion of FJ tube with tip of feeding tube as lead point. Reduction of bowel loops was achieved by gentle compression of distal part and are found to be viable. FJ tube was then removed and repositioned after which the obstruction got relieved. Intussusception is an extremely rare complication of FJ, where the clinical presentation can be likely to the various causes of small bowel obstruction. The fatal complications like intussusception in FJ can be prevented by remembering some technical considerations, such as attaching a 4-5 cm segment of the jejunum to the abdominal wall rather than a single-point fixation and maintaining a minimum distance of 15 cm between the duodenojejunal (DJ) flexure and the FJ site.

Feeding jejunostomy (FJ) is done as a part of significant upper gastrointestinal surgical procedures for patients who cannot tolerate enteral feeds. This procedure is related to different mechanical, infective, and metabolic inconveniences. However, closed-bowel loop obstruction following FJ is rare. We report an unusual complication of closed-bowel loop obstruction in the postoperative period of FJ done for a locally advanced carcinoma of gastroesophageal (GE) junction for enteral access in a 67-year-old male patient. This patient required an emergency laparotomy, to forestall exacerbating of abdomen distension which could have led to gastric ischemia and perforation following obstruction. A redo FJ was done, and the patient had an uneventful postoperative recovery. Therefore, surgeons should have high clinical suspicion for a rarer complication like a closed-loop obstruction in a patient with upper abdominal pain and distension without vomiting following FJ.
UNASSIGNED: Balamurugan S, Aslam MM, Kadambari D, et al. Closed-bowel Loop Obstruction-An Unusual and Forgotten Complication of Feeding Jejunostomy: Case Report. Euroasian J Hepato-Gastroenterol 2022;12(2):92-94.

Established consensus suggests that enteral nutrition is more beneficial in patients with a functioning gut than parenteral nutrition. It helps in early physical rehabilitation from a disease or surgical stress and is associated with fewer complications compared to parenteral nutrition. Jejunal feeding is one of the routine modes of enteral nutrition in patients with gastric dysfunction, either due to surgery or critical illness. Various complications have been reported when using feeding tubes, grouped as mechanical, infectious, gastrointestinal, and metabolic. Here, we report an unusual case of a 47-year male with a history of prepyloric perforation repair leak who presented to us on postoperative day 14 with an enterocutaneous fistula and a feeding jejunostomy tube in situ. He was evaluated and managed conservatively and discharged on enteral feeds, both orally and via a jejunostomy tube. One month after discharge, he presented with features of intestinal obstruction with a missing jejunostomy tube. Radiological investigations suggested enteral migration of the jejunostomy tube, which was managed non-operatively, and the patient was discharged on day three post-admission after per rectal expulsion of the tube.

The purpose of this study was to investigate hospital variation in the placement, surgical techniques, and safety of feeding jejunostomies (FJ) during minimally invasive esophagectomy (MIE) in the Netherlands. This nationwide cohort study analyzed patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) that underwent MIE for cancer. Hospital variation in FJ placement rates were investigated using case-mix corrected funnel plots. Short-term outcomes were compared between patients with and without FJ using multilevel multivariable logistic regression analysis. The incidence of FJ-related complications was described and compared between hospitals performing routine and non-routine placement (≥90%−<90% of patients). Between 2018−2020, an FJ was placed in 1481/1811 (81.8%) patients. Rates ranged from 11−100% among hospitals. More patients were discharged within 10 days (median hospital stay) without FJ compared to patients with FJ (64.5% vs. 50.4%; OR: 0.62, 95% CI: 0.42−0.90). FJ-related complications occurred in 45 (3%) patients, of whom 23 (1.6%) experienced severe complications (≥Clavien−Dindo IIIa). The FJ-related complication rate was 13.7% in hospitals not routinely placing FJs vs. 1.7% in hospitals performing routine FJ placement (p < 0.001). Significant hospital variation in the use of FJs after MIE exists in the Netherlands. No effect of FJs on complications was observed. FJs can be placed safely, with lower FJ-related complication rates, in centers performing routine placement.

Feeding jejunostomy is a solid way for patients to maintain enteral nutrition. However, debate over the superiority of the laparoscopic vs. laparotomic method has raised concerns in recent years. This systemic review and meta-analysis aimed to compare the postoperative outcomes between these two approaches.
We searched PubMed, Embase, and Scopus from the date of inception to April 2022 for studies comparing laparoscopic and open feeding jejunostomy. Study characteristics and outcomes were extracted from the included articles. The primary outcome was the relative risk (RR) of postoperative complications in each group. We also analyzed the major/minor complication rates and operations, excluding major concomitant procedures. The risk of bias of included studies were assessed using the ROBINS-I tool. The certainty of evidence was rated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).
A total of seven retrospective studies with 1195 patients in total were included in this systemic review and meta-analysis. Laparoscopic feeding jejunostomy carried a significantly lower postoperative complication rate (RR: 0.62; 95% CI, 0.42-0.91, p = 0.02, low certainty of evidence) compared with laparotomy, and the heterogeneity was moderate (I2 = 34%, p = 0.18). After excluding major concomitant procedures, the RR between the laparoscopic and open group was 0.48 (95% CI, 0.33-0.70, p < 0.001, low certainty of evidence), suggesting that the laparoscopic approach was superior in terms of postoperative complications.
Our results indicate that laparoscopic feeding jejunostomy might reduce the postoperative overall complication rate compared with open feeding jejunostomy.