Images for surgeons
391
methods to unblock the tube, even slightly withdrawing the NJ tube, the NJ tube could not be unblocked, thus unable to be used. The decision to remove the NJ tube was made and urgent reinsertion arranged. Upon withdrawal of the NJ tube, and with great shock, the reason for blockage was established (Fig. 1). The NJ tube tip was in a complex knot! The tip of the NJ tube managed to coil and knot itself in this complex arrangement, unseen by the surgical consultants of the UGI department. No method would have unblocked this tube. The ward management of blocked feeding tube is usually successful,3 and the nursing staff know the tricks in managing them; however, I make the suggestion of considering if the tube is nonresponsive to bedside unblocking techniques that there could be the possibility of the tube being in a ‘knot’ rendering the tube nonfunctional and forming an annoying, stubborn and blocked tube and just proceed to remove the tube. Fig. 1. Intraintestinal complex knot formed by the nasojejunal feeding tube tip.
unblocking tubes, occasionally it is unsuccessful and the regretful decision to removal and replace is required. We report a case of this blocked nasojejunal (NJ) feeding tube at the Royal Prince Albert Hospital. The NJ feeding tube was inserted intraoperatively post-gastroscopy and confirmed by intraoperative image intensifier radiography (tube at 135 cm) with use of contrast in a 37-year-old man who had significantly lost weight over 10 months after a Whipple’s procedure (pancreatoduodenectomy) and not tolerating sufficient oral nutrition. The intention of the feeding tube was to increase enteral nutritional supplementation,4,5 and to receive dietary/nutritional education while an inpatient. The feeding tube was initially functioning well and the nursing staff reported no functional issues. Flow issues did become problematically apparent and the tube was blocked 3 days after insertion. Despite conventional and non-conventional bedside
References 1. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad. Med. J. 2002; 78: 198–204. 2. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J. Clin. Nurs. 2001; 10: 482–90. 3. Nicholson LJ. Declogging small-bore feeding tubes. JPEN J. Parenter. Enteral Nutr. 1987; 11: 594–7. 4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945–8. 5. Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin. Gastroenterol. 1988; 2: 815–47.
James Salinas, BSc, MBBS Charbel Sandroussi, MBBS (Hons), MMSc, FRACS General Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia doi: 10.1111/ans.12944
An unusual cause of bowel obstruction from a feeding jejunostomy A 54-year-old man underwent an Ivor–Lewis oesophagectomy with pyloromyotomy for a gastrointestinal stromal tumour in the lower third of the oesophagus. A 14 French MIC* gastrostomy feeding tube (Kimberley Clark, Ltd., NSW, Australia) was inserted by performing a serosal ‘Witzel’ tunnel. In this technique, an opening is created in the jejunum and the bowel is then plicated to cover the feeding tube with the external surface of the jejunum and attached to the undersurface of the anterior abdominal wall. Jejunostomy feeds were started on the first post-operative day and the caloric content was gradually increased without complication. A gastro graffin swallow study was performed on day 7 showing no leak from the oesophago-gastric anastomosis. Oral fluids were commenced. On the 12th post-operative day, jejonostomy feeds were stopped as the patient was tolerating a pureed diet. He was discharged the next day with a plan for removal of the jejonostomy tube after 4 weeks. © 2015 Royal Australasian College of Surgeons
The patient presented to the emergency department 11 days postdischarge (post-operative day 24) with pain over the jejunostomy site that was worse with movement. He was examined in the emergency department and no abnormality was found. He was sent home with advice to undertake 20-mL flushes of the jejunostomy tube, which he commenced on returning home. Three days later (2 weeks post-discharge), the patient was readmitted with severe cramping abdominal pain focussed around the feeding jejunostomy point of insertion. The patient had experienced some nausea and vomiting although the patient’s bowels had opened. On examination, there was no sign of peritonism. No further flushes of the jejunostomy tube were performed. A computed tomography (CT) scan found no abnormality and the patients symptoms resolved following fasting. The patient was discharged home, but re-presented within 12 h of resuming oral intake with similar symptoms. On re-review of the CT scan by the surgical team, attention was drawn to the large volume of the jejunostomy balloon. The balloon appeared to occupy a considerable if
392
Images for surgeons
Fig. 1. Axial and coronal views showing the jejunostomy balloon occupying much of the lumen and thereby obstructing the small bowel (red arrow). The balloon is usually filled between 1.5 and 2.0 mL; however, flushing of the incorrect lumen can result in up to 20 mL of fluid filling the balloon without rupturing.
not the entire diameter of the small bowel (Fig. 1a,b). Despite this, there was no marked dilatation of the proximal small bowel. A total of 20 mL of fluid was removed from the balloon with 1.5 mL remaining (Fig. 1c). Following this simple intervention, the patient was relieved of his obstructive symptoms and was discharged home. He had no further symptoms and the jejunostomy tube was removed 4 weeks later. In retrospect, it is clear that ‘flushing of the tube’was done through the port for the balloon rather than the port for the lumen. This resulted in inflation of the balloon contributing to the obstructive symptoms. Although the guidelines suggest a filling volume of 2–3 mL, it is in fact possible to fill 20 mL of fluid in the balloon without it rupturing (Fig. 1c, lower). Feeding jejunostomies are frequently used following major upper gastrointestinal surgery to provide a means of early enteral nutrition. It is associated with a low complication rate and a mortality rate of less than 1%. However, complications have been reported in adults1 and infants.2 The most common complications include skin erosion at the site of catheter entry and gastrointestinal symptoms including diarrhoea and early satiety.3 Transmural necrosis and bowel perforation has also been reported from impacted enteral nutrition proximal to a blocked tube. There has also been a reported case of abscess following catheter dislodgement4 and small-bowel necrosis.5,6 There is one reported case of pressure necrosis (of the small bowel), following over-distension of a catheter feeding balloon with subsequent abscess formation leading to death from septicaemia.7 A broad-based attachment of the jejunal wall to the peritoneum at the place of entry of the catheter was used, and this has been described previously. In contrast to other studies, our unit commences enteral nutrition day 1 post-operatively as opposed to an average of 10 days reported elsewhere. As a general rule, in cases of small-bowel obstruction, tube feeding should be discontinued immediately and total parenteral nutrition considered.5 Given the spectrum of complications associated with jejunostomies, it is important to decide early whether surgical intervention is necessary. Abdominal CT scans and contrast radiography either as a gastrograffin upper gastrointestinal series or through the tube is useful.6,8 In our case, the CT scan provided a clue to the diagnosis.
The recommended capacity of the balloon is up to 3 mL, but as we observed, over 20 mL of fluid can be pumped into it without rupturing the balloon. While using these tubes for feeding, there is a potential for flushes being performed through the wrong lumen. Physicians and nurses should recognize the potential for feeding tubes to cause bowel obstruction because of over inflation of the balloon and pay attention particularly to patient education.
References 1. Tibbitts GM, Sorrell RJ. Duodenal obstruction from a gastric feeding tube. N. Engl. J. Med. 1999; 340: 970–1. 2. Fonkalsrud EW. Intestinal obstruction from gastrostomy tube in infants. J. Pediatr. 1966; 69: 809–11. 3. Yagi M, Hashimoto T, Nezuka H et al. Complications associated with enteral nutrition using catheter jejunostomy after esophagectomy. Surg. Today 1999; 29: 214–8. 4. Wakefield SE, Mansell NJ, Baigrie RJ, Dowling BL. Use of a feeding jejunostomy after oesophagogastric surgery. Br. J. Surg. 2005; 82: 811–3. 5. Rai J, Flint LM, Ferrara JJ. Small bowel necrosis in association with jejunostomy tube feedings. Am. Surg. 1996; 62: 1050–4. 6. Lawlor DK, Inculet RI, Malthaner RA. Small-bowel necrosis associated with jejunal tube feeding. Can. J. Surg. 1998; 41: 459–62. 7. Chester JF, Turnbull AR. Intestinal obstruction by overdistension of a jejunostomy catheter balloon: a salutary lesson. JPEN J. Parenter. Enteral Nutr. 1988; 12: 410–1. 8. Schunn CD, Daly JM. Small bowel necrosis associated with postoperative jejunal tube feeding. J. Am. Coll. Surg. 1995; 180: 410–6.
Jurstine Daruwalla,* MBBS, PhD David Murray,† BMed, FRACS Girish Pande,† MBBS, FRACS *Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia and †Department of Surgery, Launceston General Hospital, University of Tasmania, Launceston, Tasmania, Australia doi: 10.1111/ans.12991
© 2015 Royal Australasian College of Surgeons
391
methods to unblock the tube, even slightly withdrawing the NJ tube, the NJ tube could not be unblocked, thus unable to be used. The decision to remove the NJ tube was made and urgent reinsertion arranged. Upon withdrawal of the NJ tube, and with great shock, the reason for blockage was established (Fig. 1). The NJ tube tip was in a complex knot! The tip of the NJ tube managed to coil and knot itself in this complex arrangement, unseen by the surgical consultants of the UGI department. No method would have unblocked this tube. The ward management of blocked feeding tube is usually successful,3 and the nursing staff know the tricks in managing them; however, I make the suggestion of considering if the tube is nonresponsive to bedside unblocking techniques that there could be the possibility of the tube being in a ‘knot’ rendering the tube nonfunctional and forming an annoying, stubborn and blocked tube and just proceed to remove the tube. Fig. 1. Intraintestinal complex knot formed by the nasojejunal feeding tube tip.
unblocking tubes, occasionally it is unsuccessful and the regretful decision to removal and replace is required. We report a case of this blocked nasojejunal (NJ) feeding tube at the Royal Prince Albert Hospital. The NJ feeding tube was inserted intraoperatively post-gastroscopy and confirmed by intraoperative image intensifier radiography (tube at 135 cm) with use of contrast in a 37-year-old man who had significantly lost weight over 10 months after a Whipple’s procedure (pancreatoduodenectomy) and not tolerating sufficient oral nutrition. The intention of the feeding tube was to increase enteral nutritional supplementation,4,5 and to receive dietary/nutritional education while an inpatient. The feeding tube was initially functioning well and the nursing staff reported no functional issues. Flow issues did become problematically apparent and the tube was blocked 3 days after insertion. Despite conventional and non-conventional bedside
References 1. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad. Med. J. 2002; 78: 198–204. 2. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J. Clin. Nurs. 2001; 10: 482–90. 3. Nicholson LJ. Declogging small-bore feeding tubes. JPEN J. Parenter. Enteral Nutr. 1987; 11: 594–7. 4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945–8. 5. Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin. Gastroenterol. 1988; 2: 815–47.
James Salinas, BSc, MBBS Charbel Sandroussi, MBBS (Hons), MMSc, FRACS General Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia doi: 10.1111/ans.12944
An unusual cause of bowel obstruction from a feeding jejunostomy A 54-year-old man underwent an Ivor–Lewis oesophagectomy with pyloromyotomy for a gastrointestinal stromal tumour in the lower third of the oesophagus. A 14 French MIC* gastrostomy feeding tube (Kimberley Clark, Ltd., NSW, Australia) was inserted by performing a serosal ‘Witzel’ tunnel. In this technique, an opening is created in the jejunum and the bowel is then plicated to cover the feeding tube with the external surface of the jejunum and attached to the undersurface of the anterior abdominal wall. Jejunostomy feeds were started on the first post-operative day and the caloric content was gradually increased without complication. A gastro graffin swallow study was performed on day 7 showing no leak from the oesophago-gastric anastomosis. Oral fluids were commenced. On the 12th post-operative day, jejonostomy feeds were stopped as the patient was tolerating a pureed diet. He was discharged the next day with a plan for removal of the jejonostomy tube after 4 weeks. © 2015 Royal Australasian College of Surgeons
The patient presented to the emergency department 11 days postdischarge (post-operative day 24) with pain over the jejunostomy site that was worse with movement. He was examined in the emergency department and no abnormality was found. He was sent home with advice to undertake 20-mL flushes of the jejunostomy tube, which he commenced on returning home. Three days later (2 weeks post-discharge), the patient was readmitted with severe cramping abdominal pain focussed around the feeding jejunostomy point of insertion. The patient had experienced some nausea and vomiting although the patient’s bowels had opened. On examination, there was no sign of peritonism. No further flushes of the jejunostomy tube were performed. A computed tomography (CT) scan found no abnormality and the patients symptoms resolved following fasting. The patient was discharged home, but re-presented within 12 h of resuming oral intake with similar symptoms. On re-review of the CT scan by the surgical team, attention was drawn to the large volume of the jejunostomy balloon. The balloon appeared to occupy a considerable if
392
Images for surgeons
Fig. 1. Axial and coronal views showing the jejunostomy balloon occupying much of the lumen and thereby obstructing the small bowel (red arrow). The balloon is usually filled between 1.5 and 2.0 mL; however, flushing of the incorrect lumen can result in up to 20 mL of fluid filling the balloon without rupturing.
not the entire diameter of the small bowel (Fig. 1a,b). Despite this, there was no marked dilatation of the proximal small bowel. A total of 20 mL of fluid was removed from the balloon with 1.5 mL remaining (Fig. 1c). Following this simple intervention, the patient was relieved of his obstructive symptoms and was discharged home. He had no further symptoms and the jejunostomy tube was removed 4 weeks later. In retrospect, it is clear that ‘flushing of the tube’was done through the port for the balloon rather than the port for the lumen. This resulted in inflation of the balloon contributing to the obstructive symptoms. Although the guidelines suggest a filling volume of 2–3 mL, it is in fact possible to fill 20 mL of fluid in the balloon without it rupturing (Fig. 1c, lower). Feeding jejunostomies are frequently used following major upper gastrointestinal surgery to provide a means of early enteral nutrition. It is associated with a low complication rate and a mortality rate of less than 1%. However, complications have been reported in adults1 and infants.2 The most common complications include skin erosion at the site of catheter entry and gastrointestinal symptoms including diarrhoea and early satiety.3 Transmural necrosis and bowel perforation has also been reported from impacted enteral nutrition proximal to a blocked tube. There has also been a reported case of abscess following catheter dislodgement4 and small-bowel necrosis.5,6 There is one reported case of pressure necrosis (of the small bowel), following over-distension of a catheter feeding balloon with subsequent abscess formation leading to death from septicaemia.7 A broad-based attachment of the jejunal wall to the peritoneum at the place of entry of the catheter was used, and this has been described previously. In contrast to other studies, our unit commences enteral nutrition day 1 post-operatively as opposed to an average of 10 days reported elsewhere. As a general rule, in cases of small-bowel obstruction, tube feeding should be discontinued immediately and total parenteral nutrition considered.5 Given the spectrum of complications associated with jejunostomies, it is important to decide early whether surgical intervention is necessary. Abdominal CT scans and contrast radiography either as a gastrograffin upper gastrointestinal series or through the tube is useful.6,8 In our case, the CT scan provided a clue to the diagnosis.
The recommended capacity of the balloon is up to 3 mL, but as we observed, over 20 mL of fluid can be pumped into it without rupturing the balloon. While using these tubes for feeding, there is a potential for flushes being performed through the wrong lumen. Physicians and nurses should recognize the potential for feeding tubes to cause bowel obstruction because of over inflation of the balloon and pay attention particularly to patient education.
References 1. Tibbitts GM, Sorrell RJ. Duodenal obstruction from a gastric feeding tube. N. Engl. J. Med. 1999; 340: 970–1. 2. Fonkalsrud EW. Intestinal obstruction from gastrostomy tube in infants. J. Pediatr. 1966; 69: 809–11. 3. Yagi M, Hashimoto T, Nezuka H et al. Complications associated with enteral nutrition using catheter jejunostomy after esophagectomy. Surg. Today 1999; 29: 214–8. 4. Wakefield SE, Mansell NJ, Baigrie RJ, Dowling BL. Use of a feeding jejunostomy after oesophagogastric surgery. Br. J. Surg. 2005; 82: 811–3. 5. Rai J, Flint LM, Ferrara JJ. Small bowel necrosis in association with jejunostomy tube feedings. Am. Surg. 1996; 62: 1050–4. 6. Lawlor DK, Inculet RI, Malthaner RA. Small-bowel necrosis associated with jejunal tube feeding. Can. J. Surg. 1998; 41: 459–62. 7. Chester JF, Turnbull AR. Intestinal obstruction by overdistension of a jejunostomy catheter balloon: a salutary lesson. JPEN J. Parenter. Enteral Nutr. 1988; 12: 410–1. 8. Schunn CD, Daly JM. Small bowel necrosis associated with postoperative jejunal tube feeding. J. Am. Coll. Surg. 1995; 180: 410–6.
Jurstine Daruwalla,* MBBS, PhD David Murray,† BMed, FRACS Girish Pande,† MBBS, FRACS *Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia and †Department of Surgery, Launceston General Hospital, University of Tasmania, Launceston, Tasmania, Australia doi: 10.1111/ans.12991
© 2015 Royal Australasian College of Surgeons
