Bowel obstruction associated with a feeding jejunostomy and its

We reviewed 100 consecutive patients who underwent thoracoscopic esophagectomy with gastric tube reconstruction and placement of a jejunostomy ... Skiptomaincontent Advertisement SearchallBMCarticles Search DownloadPDF Researcharticle OpenAccess Published:25June2019 Bowelobstructionassociatedwithafeedingjejunostomyanditsassociationtoweightlossafterthoracoscopicesophagectomy HiroyukiKitagawa1,TsutomuNamikawa1,JunIwabu1,SunaoUemura1,MasayaMunekage1,KeiichiroYokota1,MichiyaKobayashi2&KazuhiroHanazaki1  BMCGastroenterology volume 19,Article number: 104(2019) Citethisarticle 3586Accesses 9Citations Metricsdetails AbstractBackgroundOuraimwastoclarifytheincidenceofbowelobstructionassociatedwithafeedingjejunostomy(BOFJ)afterthoracoscopicesophagectomyanditsassociationtocharacteristicsandpostoperativechangeinbodyweight.MethodsWereviewed100consecutivepatientswhounderwentthoracoscopicesophagectomywithgastrictubereconstructionandplacementofajejunostomyfeedingcatheterforesophagealcancer.TheincidenceofBOFJwasevaluatedandthechangeinbodyweightaftersurgerywascomparedbetweenpatientswithandwithoutBOFJ.ResultsBOFJdevelopedin17patients.ComparedtopatientswithoutBOFJ,thosewithBOFJhadahigherpreoperativebodymassindex(23.3 kg/m2versus20.9 kg/m2,P = 0.022),andgreaterpostoperativebodyweightlossrate:3 month,decreaseto84.2%ofinitialbodyweightversus89.3%(P = 0.002).PatientswithBOFJhadshorterdistancebetweenthejejunostomyandmidline(40 mmversus48 mm,P = 0.011)comparedtopatientswithoutBOFJ.Onmultivariateanalysis,higherpreoperativebodymassindex(oddsratio(OR) = 9.248;95%confidenceinterval(CI) = 1.344–63.609;p = 0.024),higherpostoperativeweightlossat3 months(OR = 8.490;95%CI = 1.765–40.837,p = 0.008),andshorterdistancebetweenthejejunostomyandmidline(OR = 8.160;95%CI = 1.675–39.747,p = 0.009)wereindependentlyassociatedwithBOFJ.ConclusionPatientsofBOFJhadgreaterpreoperativebodymass,shorterdistancebetweenjejunostomyandmidline,andgreaterpostoperativeweightloss. 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BackgroundEsophagectomywithradicallymphadenectomyisthemaintreatmentforesophagealcancer.However,esophagectomyisassociatedwithahighincidenceofpostoperativecomplications[1],evenwhenalessinvasivethoracoscopicprocedureisused[2,3].Inaddition,reconstructionofthegastrictube,whichiscommonlyrequiredwithesophagectomy,isassociatedwithahighincidenceofanastomoticleakage[1].Fromaclinicalperspective,postoperativeweightlossiscommonafteresophagectomy,evenintheabsenceofanycomplications[4],withsevereweightlossbeingassociatedwithapoorprognosis[5].Earlyenteralnutritionafteresophagectomyisrecommended,withinsertionofafeedingcatheterduringtheesophagectomybeingusefulforanappropriatenutritionalstrategyaftersurgery[6,7].Asperpreviouslypublishedmethods,weroutinelycreateafeedingjejunostomyduringesophagectomyinourinstitution,usingacatheter,andinitiateenteralnutritiononpostoperativeday1[4].Aswell,patientscontinuewithenteralnutritionalsupplementationafterdischargeuntiltheirdietaryintakeissufficient.Despitethisaggressivenutritionalstrategy,morethanhalfofpatientsexperiencea > 10%weightlossduringthefirst6 monthsaftersurgery[4].Moreover,thefeedingcathetercansometimescausebowelobstruction,requiringemergentsurgeryfortreatment.Therefore,theaimofourstudywastoclarifytheincidenceofbowelobstructionassociatedwithafeedingjejunostomy(BOFJ)afterthoracoscopicesophagectomy(TSE)andtoevaluatetheassociationbetweenBOFJandthepatients’characteristicsorpostoperativecourseofchangeinbodyweight(BW).MethodsThiswasaretrospectiveobservationalstudyof100consecutivepatientswhounderwentTSEforesophagealcancer,followedbygastrictubereconstruction,withplacementofajejunostomyfeedingcatheter,atourinstitution,betweenJuly2009andMay2017.Patientstreatedusingaloweresophagectomy,viaanabdominalapproach,wereexcluded.Preoperatively,allpatientsunderwentacomprehensiveexamination,includingendoscopy,computedtomography(CT),bariumswallowradiography,andbiochemicalbloodtests.Neo-adjuvantchemotherapy,usingcisplatinandfluorouracil,withorwithoutdocetaxel,wasadministeredtopatientsdiagnosedwithclinicalstageII,IIIandIVcancer,aspertheresultofJapaneseclinicalstudy[8].ThoracoscopicMcKeownesophagectomywithmediastinaldissectionwasperformedinproneposition.Afterthoracoscopicesophagectomy,patientswereplacedinsupineposition,gastricmobilizationwithabdominaldissectionandgastrictubereconstructionwasperformed.Informedconsentwasomittedandinformationofthisstudywasdisclosedintheformofopt-outonourhospitalwebsite.InsertionofafeedingcatheterinthejejunumA30 cm,9Fr,feedingcatheter(KangarooJejunostomyCatheter,CovidienJapan,Tokyo,Japan)wasinsertedviaa7 cmmiddleincisionafterlaparoscopicgastricmobilizationandabdominallymphnodesdissectionintothejejunum,20 cmdistalfromTreitzligament.ThecatheterwassecuredusingtheWitzelprocedure,withpursestringsuturesandthreeadditionalsuturesusingabsorbablethreadoverthecatheter.Inaddition,fourfixedperitoneum-jejunumsuturesusingnon-absorbablesilkthreadwereplacedaroundthepuncturesiteinthejejunum.PostoperativemanagementPatientsweretransferredtothesurgicalintensivecareunit,withmechanicalventilationprovidedforthefirstnight.Onthemorningofpostoperativeday1,patientswereweanedofftheventilatorandtherehabilitationprograminitiated.Enteralnutrition,usingaliquiddietviathefeedingjejunostomycatheter,wasalsoinitiatedonpostoperativeday1,withacaloricintakeof30 kcal/h.Thethoracicdraintubewasremovedonpostoperativeday5–7,andoralintakewasinitiatedonpostoperativeday7,intheabsenceofanyevidenceofanastomoticleakage[9].Patientsweredischargedwhentheywerecomfortablewithoralintake;follow-upvisitswerescheduledatthehospitalat1,3,6,9,and12 monthsaftersurgery,withsubsequentfollow-upevery3to6 monthsforanadditionalyear.Patientswereadvisedtomaintainanenteralnutritionof200to600 kcal/day,viathefeedingcatheter,whentheirdailyoralintakewasinsufficient.Thefeedingcatheterwasremovedwhendietaryintakewassufficienttomeetnutritionalneeds.DiagnosisofBOFJWhenthepatientscomplainedofacuteepigastralgiawithawhirlsignvisibleonCT(Fig. 1a,b)atthesiteoffeedingjejunostomy,wediagnosedasBOFJ.WhenthewhirlsignwasnotdetectedonCT,thepatientsweretreatedconservatively.Fig.1a.Computedtomographyshowingadilationoftheduodenumina62-years-oldmanwhohadbeencomplainingofacuteupperabdominalpainfor18 monthsafteresophagectomy.b.Anobstructionofthejejunum,atthesiteofthefeedingjejunostomy,wasidentified(whirlsign;arrow),withtwistingofthemesentericvesselsFullsizeimageOutcomeparametersPatients’characteristics,surgicaloutcomesandpostoperativeclinicaloutcomeswereincludedintheanalysis.Patients’characteristicsincluded:age;sex;cancerhistology;clinicalcancerstage,accordingtothe7theditionoftheTNMclassification[10];preoperativeBW;preoperativebodymassindex(BMI);andtheuseofneo-adjuvantchemotherapy.Surgicaloutcomesincluded:theuseoflaparoscopy;thereconstructionmethod(circularanastomosisorhand-sewn);totaloperativetime(calculatedfromthetimeofskinincisiontothetimeofpostoperativeradiographyexamination);andtotalbloodlossvolume.Postoperativeclinicaloutcomesincluded:complications,suchaspneumonia,anastomoticleakage,recurrentnervepalsy,andsurgicalsiteinfection;lengthofhospitalstay;andchangeinbodyweight,measuredat1,3,6,and12 monthsafterthesurgery.Inpatient’sstature,wecalculatedthelengthoftheabdominalaxis(fromxiphoidprocesstotopofpubis),distancebetweenthesiteofjejunostomyandmidline,navelline,andxiphoidprocesslineonCTscan.StatisticalanalysisForanalysis,patientswereclassifiedintotwogroups,theBOFJgroup,formedofpatientsrequiringsurgeryforthetreatmentofBOFJaftertheprimarysurgery,andtheNon-BOFJgroup.Patientcharacteristics,surgicalandclinicaloutcomesandthechangeinBWaftersurgerywerecomparedbetweenthetwogroups.WealsoanalyzedarelationshipbetweentheBOFJandthepatient’sstature.Continuousvariablesarereportedasamedianandtheassociatedrange.TheMann-WhitneyUtestwasusedtoevaluatedifferencesincontinuousvariablesbetweenthetwogroups,withPearson’schi-squaredtestusedforcategoricalvariables.Kaplan-Meierestimatesofaccumulatedoccurrenceratewerecalculated.LogisticregressionanalysiswasusedtoidentifyfactorsassociatedwithBOFJ.Receiveroperatingcharacteristiccurveanalysiswasusedtodeterminetheoptimalcut-offvaluesformultivariateanalysisofpatientswithBOFJ.AllanalyseswereperformedusingJMP13(SASInstituteInc.,Cary,NC,USA),withaP-value