Purely laparoscopic feeding jejunostomy: a procedure which ...

Laparoscopic feeding jejunostomy was first described in 1990 by O'Regan [7]. Compared to the conventional open procedure, laparoscopic approach ... Skiptomaincontent Advertisement SearchallBMCarticles Search DownloadPDF Researcharticle OpenAccess Published:13January2021 Purelylaparoscopicfeedingjejunostomy:aprocedurewhichdeservesmoreattention Hsin-I.Tsai1,2,3 na1,Ta-ChunChou4 na1,Ming-ChinYu2,3,5,6,Chun-NanYeh2,5,Meng-TingPeng7,Chia-HsunHsieh2,7,8,Po-JungSu2,7,9,Chiao-EnWu2,7,Yung-ChiaKuo2,3,7,Chien-ChihChiu10&Chao-WeiLee  ORCID:orcid.org/0000-0002-6853-45572,3,5  BMCSurgery volume 21,Article number: 37(2021) Citethisarticle 2497Accesses 1Citations 1Altmetric Metricsdetails AbstractBackgroundLaparoscopicprocedurehasinherentmeritsofsmallerincisions,bettercosmesis,lesspostoperativepain,andearlierrecovery.Inthecurrentstudy,wepresentedourmethodofpurelylaparoscopicfeedingjejunostomyandcompareditsresultswiththatofconventionalopenapproach.MethodsWeretrospectivelyreviewedourpatientsfrom2012to2019whohadreceivedeitherlaparoscopicjejunostomy(LJ,n = 29)oropenones(OJ,n = 94)inChangGungMemorialHospital,Linkou.Peri-operativedataandpostoperativeoutcomeswereanalyzed.ResultsInthecurrentstudy,weemployed3-0Vicryl,insteadofV-locbarbedsutures,forlaparoscopicjejunostomy.ThemeanoperativedurationofLJgroupwasabout30 minlongerthantheOJgroup(159 ± 57.2 minsvs128 ± 34.6 mins;P = 0.001).Therewerenointraoperativecomplicationsreportedinbothgroups.ThepatientsintheLJgroupsufferedsignificantlylesspostoperativepainthanintheOJgroup(meanNRS2.03 ± 0.9vs.2.79 ± 1.2;P = 0.002).Themajorityofpatientsinbothgroupsreceivedearlyenteralnutrition( 0.05).Ontheotherhand,patientsintheLJgroupweresignificantlyyoungerthanpatientsintheOJgroup(meanage54.3 ± 9.5vs.61.6 ± 12.3,P = 0.004).Asfortheindicationsforsurgery,malignancyremainsthemostcommonindicationforjejunostomy,withmorethan80%ofpatientsinbothgroupsundergoingoperationduetounderlyingmalignancy.Amongmalignancies,esophagealcancerwasthemostcommontype,followedbyhead/neckcancerandgastriccancer.Inthemeanwhile,itisnoteworthythat18.1%ofOJgrouphadnon-cancerrelatedindications,comparedtoonly3.4%intheLJgroup(P = 0.070).Table1PatientdemographicsFullsizetableAsforsurgicalvariables,theLJgrouphadasignificantlylongeroperationtimethantheOJgroup(159 ± 57.2 minsvs.128 ± 34.6 mins,P = 0.001).Onlyonepatientunderwentconventionalopenjejunostomyunderlocalanesthesia.Forty-twopatients(45.2%)intheOJgroupunderwentconcomitantprocedures,incontrasttoonly5patients(17.2%)intheLJgroup(P = 0.008).Noseriousintraoperativecomplicationswererecordedinbothgroups(Table2).Table2SurgicalvariablesofpatientsreceivingfeedingjejunostomyFullsizetableTable3summarizedthepostoperativeoutcomefollowingfeedingjejunostomy.Thepainscaleonpostoperativeday1(POD1)wassignificantlylowerintheLJgroupthanintheOJgroup(P = 0.002).Theimplementationofearlyenteralfeeding,i.e.feedingwithin48 hofsurgery,wascomparablebetweenthetwogroups(P = 0.216).Themeanfeedingtimewasaround2 dayspostoperativelyinbothgroups(P = 0.525).Theoccurrenceoflatepostoperativecomplicationswasminimalinbothgroups(P = 1.000).Asfortheapplicationofchemotherapy,therewasnosignificantdifferenceintermsofdateofchemotherapyinitiationbetweenthetwogroups.Bothgroupshadstartedtheirchemotherapyatabout20 daysaftersurgery(P = 0.950).Table3Post-operativeoutcomeofpatientsreceivingfeedingjejunostomyFullsizetableThemeandurationofenteralfeedingwas8.70 ± 2.00 monthsand10.36 ± 1.69 monthsintheLJandOJgroups,respectively(P = 0.610).Morethan90%ofthejejunostomies(93.1%intheLJgroupand92.6%intheOJgroup,P = 1.000)werestillfunctionalafterperiodsoffeeding.Amongthesepatientswithfunctionaljejunostomies,continuedenteralfeedingviajejunostomywasnecessaryinsomepatientsduetopersistentorprogressiveunderlyingdiseasewhileothersmayhavetheirstomiesclosedaftercurativetreatmentwascompleted.DiscussionLaparoscopicsurgeryhasbeenproventobeaneffectivesurgicalapproachinmanyabdominaldiseases,includingacutecholecystitis,coloncancer,andgastroesophagealrefluxdisease[25,26,27].Withimprovementsinsurgicaltechniquesandlaparoscopicinstruments,laparoscopicsurgeryhasalsoshownpromisingresultsinmajorabdominaloperationsinrecentdecades[28].Laparoscopicfeedingjejunostomy,however,didnotattractmuchattentionfromsurgeonsworldwide.Itmaybeduetothefactthatfeedingjejunostomybynatureisnotacomplexorimportantprocedure.Surgeonswouldnotspendtheirtimeinvestigatingthebenefitsofaninsignificantoperation.We,incontrast,holdtheoppositeopinion.Sinceenteralfeedingissuperiortoparenteralnutrition,feedingjejunostomyshouldbeindicatedforpatientsintoleranttoperoralfeeding.Giveninherentmeritsofsmallerincisions,bettercosmesis,lesspostoperativepain,andearlierrecovery,laparoscopicfeedingjejunostomyshouldbethepreferableapproachandthuscannotbeoverlooked!Inthecurrentstudy,wedescribedourmethodofpurelylaparoscopicfeedingjejunostomyandcomparedtheresultwiththatofconventionalopencounterpart.OurstudyisthusoneofthefirstintheEnglishliteraturetoimplytheadvantagesoflaparoscopicfeedingjejunostomyovertheopenones.SincealloftheLJinthepresentstudywereconductedbyonesinglesurgeon,wealsobelievetheresultsshouldbemorehomogeneousandreliable.Ourpurelylaparoscopicfeedingjejunostomypossessesplentyofadvantages.First,wedemonstratedthattheLJgroupdidhavesignificantlylesspainthantheOJgroup,whichalthoughwasnotasurprisingfindingbutrarelydescribed[29,30].Secondly,thepostoperativerecovery,intermsofenteralfeeding,wasnotcompromisedbythelaparoscopicapproach.Morethan85%ofpatientsintheLJgroupstartedenteralfeedingwithin48 hofsurgery,whichwassimilartopreviousstudies[30].TheinitiationofchemotherapyincancerpatientswasalsocomparablebetweenLJandOJ.Ourfindingsindicatedthatthelaparoscopicprocedurecannotonlyreducethepostoperativepainbutalsomaintaintheintrinsiceffectivenessofconventionalopenapproach.Next,inthecurrentlaparoscopicprocedure,weused3-0Vicryl,insteadofV-locbarbedsuture,fortheintracorporealsutures.SinceithasbeendescribedthattheV-locsuturesmaycausesmallbowelobstructionorileus,ourchoiceof3-0Vicrylmaythusreducetherisk[31,32,33].OnemayarguethatitwouldbeverychallengingtosecurethestichovertheperitonealsideoftheanteriorabdominalwallwithouttheaidsoffancysuturinginstrumentsuchasV-locbarbedsuture[30].Webelievethisobstaclecanbeovercomebyourtechniqueofexternalmanualpressureandpneumoperitoneumof8to10 mmHg.Furthermore,weemployedthree5 mmtrocarports,insteadof10–18 mmports,inthecurrentprocedure[10].Itwoulddefinitelyreducethescarandpostoperativepain.Lastbuttheleast,throughtheserepetitiveintracorporealsuturesandties,youngersurgeonscanexceltheirlaparoscopicsuturingtechniquesbeforeadvancingtomorecomplicatedintra-abdominaloperations.SinceitsfirstintroductionbyGaudereretal.,percutaneousendoscopicgastrostomy(PEG)hasbecomeoneofthemostpopularroutesofnutritionalsupportworldwide[34,35].Duetolowercost,lessneedforgeneralanesthesiaandlessinvasivenature,PEGhasbeenconsideredasabetterchoiceforenteralfeedingoverthesurgicalmethods.Nevertheless,complications,whichrangefromminoronessuchaswoundinfection,gastricoutletobstruction,andperitonitistomajorcomplicationsincludingbleeding,bowelperforation,andnecrotizingfasciitis,dooccurafterPEG[34].Laparoscopicjejunostomy,incontrast,wasfoundtohavefewcomplicationsbasedonthecurrentstudy.Additionally,PEGisinappropriateinpatientswithgastricorduodenalmalignancies.Moreover,PEGrequiresspecializedendoscopist,radiologists,custom-madefeedingtubes,andfixationsdevicestosecurelycompletetheprocedure.ThereplacementofPEGtubes,unliketheLJtubes,alsorequiresspecialequipment.Lastbutnottheleast,LJprovidesopportunitytoperformthoroughabdominalexplorationinthefirstplace,whichcanassesstheextentofdiseasepriortotheinitiationofchemotherapy.Theinheritmeritoflaparoscopicsurgerytoreducepost-operativeadhesionscouldalsofacilitatethefollowingcurativesurgery.GiventhesepotentialbenefitoverPEG,webelievelaparoscopicjejunostomyshouldbecomeafairalternativetoPEGinhospitalswherePEGtechniquesorfacilitiesarenotavailable.Despiteourremarkablefindings,thecurrentstudystillhadseveraldrawbacks.First,thetwogroupswerenothomogeneouslydistributed.Thereseemedtobeselectionbiaswhenperformingtheprocedure.TheLJgroupwasmuchyoungerandreceivedlesspriorabdominaloperations.TherewasalsolesscausticinjuryintheLJgroup,andmorepatientsintheOJgroupunderwentconcomitantprocedures.Webelievetherearesomeexplanations:Sincetheindexsurgeonisadedicatedsurgicaloncologist,whilethesurgeonswhoperformtheOJalsoincludegeneralsurgeons,thedistributionofpatientpopulationmaythusbeheterogeneous.Next,youngerpatientswereexpectedtohavelesscomorbiditiesandbettercardiopulmonaryreserve,whomaythussustainbetterunderpneumoperitoneum.Thehistoryofpriorabdominaloperationsandthenecessityofthoroughgastrointestinaltractevaluationincaseswithcausticinjurymayrendersurgeonslesswillingtoperformtheoperationunderlaparoscopy.Asforconcomitantprocedures,thefrequencyofconcomitantextra-abdominalprocedureswasnotthatdiversebetweenthetwogroups(17.2%and26.6%intheLJandOJgroups,respectively).Nevertheless,westillbelieveawell-designedrandomizedstudywithmatchedvariablesiswarrantedtoinvestigatetheactualeffectoflaparoscopicfeedingjejunostomy.Secondly,theoperationdurationwasabout30 minlongerintheLJgroupinthecurrentstudy.Thisprolongedoperationtimewasduetoourinitialinexperiencedtechnique.Afterexcludingthefirsttwocases,themeanoperationdurationwouldreduceto146.8 min,158 minfasterthantheinitialexperience.Webelievetheoperationdurationwouldbeevenshorterwhenthelearningcurveisovercome.Next,thereisstilladiscrepancybetweenouroperationdurationandthoseofpreviousresearch[4,10,13,14,15,17,18,19,30,36,37,38,39].Webelievethisisduetodifferentdefinitionsregardingoperationtime.Finally,thesamplesizeistoosmall;futurelargerscalestudieswithmatchedvariablesarethuswarrantedtovalidateourfindings.ConclusionInconclusion,thecurrentstudydemonstratedthatourpurelylaparoscopicfeedingjejunostomyisasafeandfeasibleprocedurewithlesspostoperativepainandexcellentpostoperativeoutcome.Inaddition,itprovidessurgeonsopportunitiestoenhanceintracorporealsuturetechniques.Therefore,webelieve,inselectedpatientssuchasthoseofyoungerage,withbetterperformancestatus,orwithoutpriorabdominaloperations,laparoscopicfeedingjejunostomyshouldbecomeastandardsurgicalprocedureandshouldnotbeneglected.Furtherlargescaleprospectivestudiesarewarrantedtovalidateourfindings. Availabilityofdataandmaterials Alldatageneratedoranalyzedduringthestudyareincludedinthispublishedarticle.Rawdatamayberequestedfromtheauthorswiththepermissionoftheinstitution. AbbreviationsBMI: Bodymassindex CGMH: ChangGungMemorialHospital ECOG: EasternCooperativeOncologyGroup Hr: Hour IRB: Institutionalreviewboards LA: Laparoscopicappendectomy LC: Laparoscopiccholecystectomy LG: Laparoscopicgastrectomy LH: Laparoscopichepatectomy LJ: Laparoscopicjejunostomy LP: Laparoscopicpancreatectomy IRB: Institutionalreviewboards NRS: Numericalratingscales OJ: Openjejunostomy POD: Post-operativeday PEG: Percutaneousendoscopicgastrostomy ReferencesZengS,XueY,ZhaoJ,LiuA,ZhangZ,SunY,etal.Totalparenteralnutritionversusearlyenteralnutritionaftercystectomy:ameta-analysisofpostoperativeoutcomes.IntUrolNephrol.2019;51(1):1–7(Epub2018/11/23).PubMed  Article  GoogleScholar  HeylandDK,CookDJ,GuyattGH.Enteralnutritioninthecriticallyillpatient:acriticalreviewoftheevidence.IntensiveCareMed.1993;19(8):435–42(Epub1993/01/01).CAS  PubMed  Article  GoogleScholar  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DownloadreferencesAcknowledgementsWearegratefultoallourcolleaguesintheDivisionofGeneralSurgery,DepartmentofSurgery,andDepartmentofHematology-Oncology,ChangGungMemorialHospital,LinkouMedicalCenter,andGraduateInstituteofClinicalMedicalSciences,ChangGungUniversityfortheirtechnicalassistance.WearealsogratefultoYi-PingLiuforherassistanceindataretrievalandprocessing.FundingThisstudywassupportedbyChangGungMemorialHospital(CMRPG3J1691andCMRPG3I0301).Thegrantssupporteddatacollection,statisticalanalysis,datainterpretation,andmanuscriptpreparation.AuthorinformationAuthornotesHsin-I.TsaiandTa-ChunChoucontributedequallytothisworkAffiliationsDepartmentofAnesthesiology,ChangGungMemorialHospital,LinkouMedicalCenter,Guishan,Taoyuan,Taiwan,RepublicofChinaHsin-I.TsaiCollegeofMedicine,ChangGungUniversity,Guishan,Taoyuan,Taiwan,RepublicofChinaHsin-I.Tsai, Ming-ChinYu, Chun-NanYeh, Chia-HsunHsieh, Po-JungSu, Chiao-EnWu, Yung-ChiaKuo & Chao-WeiLeeGraduateInstituteofClinicalMedicalSciences,ChangGungUniversity,Guishan,Taoyuan,Taiwan,RepublicofChinaHsin-I.Tsai, Ming-ChinYu, Yung-ChiaKuo & Chao-WeiLeeDepartmentofSurgery,KeelungChangGungMemorialHospital,Keelung,Taiwan,RepublicofChinaTa-ChunChouDivisionofGeneralSurgery,DepartmentofSurgery,ChangGungMemorialHospital,LinkouMedicalCenter,No.5,FuxingSt.,GuishanDist.,Taoyuan,33305,Taiwan,RepublicofChinaMing-ChinYu, Chun-NanYeh & Chao-WeiLeeDepartmentofSurgery,NewTaipeiMunicipalTu-ChengHospital(BuiltandOperatedByChangGungMedicalFoundation),Tu-Cheng,NewTaipeiCity,Taiwan,RepublicofChinaMing-ChinYuDepartmentofHematology-Oncology,ChangGungMemorialHospital,LinkouMedicalCenter,Guishan,Taoyuan,Taiwan,RepublicofChinaMeng-TingPeng, Chia-HsunHsieh, Po-JungSu, Chiao-EnWu & Yung-ChiaKuoDivisionofHematologyandOncology,DepartmentofInternalMedicine,NewTaipeiMunicipalTu-ChengHospital(BuiltandOperatedbyChangGungMedicalFoundation),Tu-Cheng,NewTaipeiCity,Taiwan,RepublicofChinaChia-HsunHsiehGraduateInstituteofDataScience,TaipeiMedicalUniversity,Taipei,Taiwan,RepublicofChinaPo-JungSuDepartmentofNursing,ChangGungMemorialHospital,LinkouMedicalCenter,Guishan,Taoyuan,Taiwan,RepublicofChinaChien-ChihChiuAuthorsHsin-I.TsaiViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarTa-ChunChouViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMing-ChinYuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChun-NanYehViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMeng-TingPengViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChia-HsunHsiehViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarPo-JungSuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChiao-EnWuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarYung-ChiaKuoViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChien-ChihChiuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChao-WeiLeeViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarContributionsHITandTCCdesignedthestudyanddraftedthemanuscript.Theycontributedequallyinthepresentstudy.MTP,CHH,PJS,CEW,andYCKcollectedtheclinicaldata,editedtheoperativeimages,andrevisedthemanuscript.PJS,whoexpertizesindatascienceandstatistics,alsoconfirmedthestatisticalanalysis.CCCassistedtheoperationsandrevisedthemanuscript.CNYandMCYperformedtheconventionalopenjejunostomy,analyzedtheclinicopathologicaldataandconductedthestatistics.CWLcoordinatedtheentirestudy,performedthelaparoscopicfeedingjejunostomy,andrevisedthemanuscript.Allauthorsreadandapprovedthefinalmanuscript.CorrespondingauthorCorrespondenceto Chao-WeiLee.Ethicsdeclarations Ethicsapprovalandconsenttoparticipate ThisstudywasapprovedbytheInstitutionalReviewBoards(CGMHIRBNo:202000084B0)ofChangGungMemorialHospital(CGMH).Forretrospectivestudy,informedconsentwaswaivedaccordingtoourinstitutionalguideline. Consentforpublication Notapplicable. Competinginterests Hsin-ITsai,Ta-ChunChou,Ming-ChinYu,Chun-NanYeh,Meng-TingPeng,Chia-HsunHsieh,Po-JungSu,Chiao-EnWu,Yung-ChiaKuo,Chien-ChihChiu,andChao-WeiLeehavenoconflictsofinterestorfinancialtiestodisclose. 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ReprintsandPermissionsAboutthisarticleCitethisarticleTsai,HI.,Chou,TC.,Yu,MC.etal.Purelylaparoscopicfeedingjejunostomy:aprocedurewhichdeservesmoreattention. BMCSurg21,37(2021).https://doi.org/10.1186/s12893-021-01050-4DownloadcitationReceived:08June2020Accepted:04January2021Published:13January2021DOI:https://doi.org/10.1186/s12893-021-01050-4SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsPurelylaparoscopicJejunostomyFeedingEnteralnutritionMinimallyinvasivesurgeryEnterostomy DownloadPDF Advertisement BMCSurgery ISSN:1471-2482 Contactus Submissionenquiries:[email protected] Generalenquiries:[email protected]