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Clinical Burden of Laparoscopic Feeding Jejunostomy Tubes
Emily a. Speer*1, Simon C. Chow2, Christy M. Dunst3, Amber L. Shada1, Valerie J. Halpin2, Kevin M. Reavis3, 1, Lee L. Swanstrom3, 1, Maria a. Cassera3
1Minimally Invasive Surgery, Providence Portland Medical Center, Portland, OR; 2Bariatric Surgery, Legacy Good Samaritan Medical Center, Portland, OR; 3Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, OR
INTRODUCTION
Feeding jejunostomy (J tube) provides enteral nutrition when oral and gastric routes are not an option. Despite the fact that J tube placement is a relatively common general surgical procedure, and most clinicians encounter challenging J tube issues, there has been little standardization in their surgical technique or postoperative care. This study aims to review the indication, efficacy and clinical burden of laparoscopic J tubes.
METHODS
All laparoscopic J tubes placed over a five year period in a general surgical practice that manages its own J tubes long-term were retrospectively reviewed. Clinical burden was measured by the number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, "other"). Tube replacement was also recorded.
RESULTS
Our study had 151 patients. Fifty-nine percent had an associated malignancy and 80% were placed concomitantly with another procedure. Thirty-five percent were placed for nutritional prophylaxis. Mean J tube duration was 225 days (2-1458). J tubes were expected to be temporary in > 90% but only 50% had sufficient oral intake for tube removal (after an average 146 days, 22-782). Tubes were removed prematurely due to patient intolerance in 8%.
There was no mortality directly related to the J tubes but 17% died of other causes with the tubes in situ. Morbidity occurred in 51% of J tubes and included clogging (12%), tube fracture (16%), dislodgement (25%), infection (17%) and "other" (leaking, erosion, etc) in 17%. The median number of adverse events per J tube was 2 (0-8). Each patient had a mean of 2.5 clinic phone calls (0-22), 0.5 ED visits (0-7), and 1.4 clinic visits (0-13), with 82% requiring additional postoperative attention to the feeding tube by a physician. Thirty-nine percent required unplanned replacements due to complications; most were changed in the office. Neither diagnosis (malignant vs benign, p=0.08) nor preoperative chemoradiation (p=0.6) significantly affected complication rates.
CONCLUSION
While laparoscopic feeding jejunostomy is necessary for some patients with orogastric failure, care of these tubes requires a substantial time commitment from both patients and providers. In this high risk population (as demonstrated by a nearly 20% unrelated mortality rate), the presence of feeding tubes leads to additional ER visits for 1/3 of patients. Furthermore, many anticipated temporary tubes ultimately become permanent. Surgeons who perform these operations should be aware of the associated high clinical burden in order to appropriately set expectations and provide necessary care.
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