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| CASE REPORT |
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| Year : 2020 | Volume
: 17
| Issue : 4 | Page : 292-294 |
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Long term complication of feeding jejunostomy – small bowel volvulus
GK Adithya, Varun Madaan, Rigved Gupta, Satya Prakash Jindal, Deepak Govil
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, Delhi, India
| Date of Submission | 26-Jul-2020 |
| Date of Acceptance | 05-Oct-2020 |
| Date of Web Publication | 24-Nov-2020 |
Correspondence Address:
Dr. G K Adithya
Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, Delhi - 110 076
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/am.am_32_19
Introduction: Feeding jejunostomy (FJ) is a lifesaving procedure on many occasions in patients requiring long term nutritional assistance. It is associated with many short and long term complications. Small bowel perforations, small bowel volvuli with infarction, intraperitoneal leaks and intussusception are well reported complications of FJ. Here we present a case report of FJ giving rise to small bowel volvulus.
Case report: An elderly male patient of 71 years with underlying systemic hypertension, diabetes mellitus, and thoracic aortic aneurysm with aortoesophageal fistula underwent feeding jejunostomy for long term feeding purpose. Feeding went on well for almost a year. He had a second intravascular procedure for type 1 endoleak. Four months following this he developed an episode of severe colicky abdominal pain associated with vomiting. He was evaluated with CECT abdomen which showed the possibility of mesenteric volvulus with small bowel obstruction at distal ileal level. Patient underwent emergency exploratory laparotomy and untwisting of mesentery with redoing of FJ distal to the previous site of FJ. There was no bowel compromise. He developed severe hypokalemia post operatively which required intra venous potassium infusion and ventilator support. With all supportive management patient continued to deteriorate and succumbed.
Keywords: Complications of feeding jejunostomy, feeding jejunostomy, small bowel volvulus
How to cite this article:
Adithya G K, Madaan V, Gupta R, Jindal SP, Govil D. Long term complication of feeding jejunostomy – small bowel volvulus. Apollo Med 2020;17:292-4 |
| Introduction | |  |
Feeding jejunostomy (FJ) is a lifesaving procedure performed in patients requiring long-term nutritional assistance, especially in upper gastrointestinal tract surgeries. It is associated with many short and long-term complications. Braga et al.[1] quote an overall complication rate of 2.9% irrespective of the technique used. Small bowel perforations, small bowel volvuli with infarction, intraperitoneal leaks, and intussusception are well-reported complications of FJ.[2] Although these are rare, can prolong patient's hospital stay with delay in the beginning of enteral nutrition. Here, we present a case of FJ complicating into small bowel volvulus culminating in death.
| Case Report | | |
An elderly male patient of 71 years with underlying systemic hypertension, diabetes mellitus with thoracic aortic aneurysm repair (endoscopic) 1 year back, presented initially with cough and hemoptysis which was treated based on the provisional diagnosis of mediastinal tuberculosis/sarcoidosis. At the same time, he was found to have aortoesophageal fistula for which he underwent open FJ for long-term nutritional purpose. The patient's feeding went on well for almost a year with minimal wound-related issues. Meanwhile patient had persistent hemoptysis which was evaluated and diagnosed to have type-1 endoleak of thoracic Aortic Aneurysm. He underwent endovascular stenting for aneurysm leak followed by endoscopy to clip the esophageal fistulous opening.
After 4 months of this intervention, the patient developed an episode of severe colicky abdominal pain associated with vomiting. This was evaluated in the emergency department with a contrast-enhanced CT scan of the abdomen, which showed “Whirlpool” appearance in the small bowel mesentery and overlying bowel loops at the distal ileal level, findings raising the possibility of mesenteric volvulus with small bowel obstruction at distal ileal level [Figure 1]. The patient was taken up for emergency exploratory laparotomy after explaining the risks associated with it. Intraoperatively there was twisting of mesentery along with its bowel in the distal ileal segment with gross dilatation of bowel proximal to it [Figure 2]. There was no bowel compromise. FJ tube had become hard and tough to bend. Untwisting of mesentery with small bowel was done and waited for the pink color of the bowel to return. In view of possible usage of the stomach as a conduit for esophagus in case aortoesophageal fistula does not heal, redo-FJ was performed distal to the previous site of FJ. The Witzel technique was used. The bowel loop was fixed to the abdominal wall proximal and distal to the FJ site with one or two sutures. The immediate postoperative period was unremarkable. He developed severe hypokalemia on postoperative day 4 which required intravenous potassium infusion and ventilatory support. With all supportive management, the patient continued to deteriorate. Eventually, he developed refractory bradycardia and asystole from which he could not be revived and succumbed. | Figure 1: Contrast-enhanced computed tomography of the abdomen showing whirlpool pattern of mesentery around feeding jejunostomy tube (arrow) with distended bowel
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 | Figure 2: Intraoperative finding of mesenteric and bowel twisting around feeding jejunostomy tube
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| Discussion | | |
Feeding jejunostomy in upper gastrointestinal conditions or surgeries is a frequent additional procedure to establish immediate postoperative nutrition. However, there are many case series and case reports reporting minor as well as major complications associated with it. In our case, the patient was on FJ feed for a long time without any near future plan for definitive surgery. Brenkman et al. showed a complication rate of 17% in patients undergoing jejunostomy placement, leading to reoperations in 3% of patients. Complications included skin leakage in 3 patients, peritoneal leakage from the insertion site in 2, luxation of the jejunostomy in 3, occlusion of the jejunostomy in 2, infection of the jejunostomy insertion site in one, and torsion of the jejunostomy in one patient. This led to reoperations in 2 (3%) patients (1 due to persistent leakage and 1 due to torsion of the jejunostomy). Seven patients (11%) had unintentionally stopped tube feeding.[3] In our case patient had mesenteric twisting (volvulus) causing small bowel volvulus. This is kind of complication is very rare and requires a high degree of clinical suspicion.
Ingrid in their study had an overall complication rate of 1.1%, all requiring relaparotomy. In one patient there was torsion of the jejunostomy catheter which they replaced with another FJ, which got obstructed again 3 days later. Internal herniation occurred in 3 patients behind jejunostomy. There was complete dislodgement of the jejunostomy catheter in 4 patients with intraperitoneal leakage among 3 patients. All were reoperated and a new jejunostomy tube was placed. Overall, five deaths (0.4%) occurred as a direct consequence of jejunostomy related complications. Complications appeared with a time duration of 14–93 days after the primary operation.[4] In our case, small bowel volvulus per se is not the direct cause of mortality, but it might have triggered the metabolic derangements which later led to the death of the patient.
Many technical changes were suggested and followed during the FJ procedure in the past to avoid these complications. Some of them are, meticulously securing the catheter to anterior abdominal wall proximal and distal to jejunostomy site, fixing a segment of small bowel the lateral abdominal wall in the left paracolic gutter to prevent bowel obstruction, inclusion or exclusion of Witzel technique, and routine use of postoperative contrast studies.[5] However, the data are lacking in proving any of these measures would prevent complications.
Is it justifiable to consider other enteral nutritional routes like gastrostomy or nasojejunal tube placement in these cases? Again the risk–benefit ratio remains the same for these techniques, one faring better than the other depending on the surgical situation we are going to face. In our case, the stomach was not an option since in the long run; it can act as a conduit to replace the esophagus. Since we were not sure of the patient getting definitive surgery in the near future, nasojejunal feeding would not have been possible for a long-term purpose. So the only option available was to place a fresh FJ tube beyond the previous FJ site and hope for the best.
| Conclusion | | |
Enteral feeding access is an inevitable procedure, so are the complications. No surgical measures have proven a hundred percent safe till now. Hence, it is wise to suspect these complications early and act accordingly to prevent catastrophic consequences.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Braga M, Gianotti L, Gentilini O, Liotta S, DiCarlo V. Feeding the gut early after digestive surgery: Results of a nine-year experience. Clin Nutr 2002;21:59-65.  |
| 2. | Sonawane RN, Thombare MM, Kumar A, Sikora SS, Saxena R, Kapoor VK, et al. Technical complications of feeding jejunostomy: A critical analysis. Trop Gastroenterol 1997;18:127-8. |
| 3. | Brenkman HJ, Roelen SV, Steenhagen E, Ruurda JP, van Hillegersberg R. Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas. Chin J Cancer Res 2017;29:333-40. |
| 4. | Han-Geurts IJ, Verhoef C, Tilanus HW. Relaparotomy following complications of feeding jejunostomy in esophageal surgery. Dig Surg 2004;21:192-6. |
| 5. | Minarich MJ, Schwarz RE. Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations. Transl Gastroenterol Hepatol 2018;3:44. |
[Figure 1], [Figure 2]
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