Surgical Oncology 1992; 1: 245-249

245

Short Report

Laparoscopic feeding jejunostomy

tube in oncology patients

L. M. ELLIS, D. B. EVANS, D. MARTIN AND D. M. OTA Department

of General Surgery and the Nutrition Support Service, University of Texas, MD Anderson Cancer Center, Houston, Texas. USA

Laparoscopic-guided groups the

pancreas

nutritional who

feeding

of patients: treated

results

for

effective

our

first

17

patients

Keywords:

cancer,

enteral

underwent

surgery

advancement

Surgical

nutrition,

for tumour

laparoscopy,

1992;

surgery

management

of benign

lithiasis,

acute

Minimally

and

in the

such as choie-

and reflux

Patients

pancreatic

tumours

or impending

nasoenteral

tubes

gastrostomy

or

tubes

enteral feeding, patients

tumour

conditions

appendicitis,

management.

significant

those

successful

esophagitis.

invasive surgery also has an important

in cancer gastric,

has been

can

obstruction

in the upper

deficits.

percutaneous

these methods with

can present

nutritional provide

role

with oesophageal,

easy

with While

only alternative,

tract.

In such

early hospital

laparotomy

Dr D. B. Evans,

Department

of General

Surgery (Box 106), Section of Endocrine Tumor Surgery, The University

of

Texas

MD

Anderson

Cancer

Center,

1515

Holcombe Boulevard, Houston, Texas 77030, USA. Presented

in part at ASPEN Clinical Congress January

Orlando, FL, USA.

The

release

for placement

often requiring

growing

gist

with

operative

of a

has been

a 3-5

the

day hospitali-

with significant

popularity

new

of neoadjuvant

gastric

[l-3].

nutrition-related

irradiation

patient

and

pancreatic

In addition,

cancers

the underlying

At The

University

of Texas,

Center,

we

initiated

MD

a complete copy. stomy

tubes

access Feeding

are

can

produce toxicity

malignancy

itself

of malnutrition. Anderson

neoadjuvant

staging evaluation

At the time

Pre-

for patients

gastrointestinal

to the development

have

therapy

the oncolo-

challenges.

and chemotherapy

dose-limiting,

may contribute

techniques, 1992,

tube

or gastrostomy

patients with gastric and pancreatic Correspondence:

This

and feeding

for the patient with cancer is presenting

access

or

and cost-

discomfort.

significant,

due to stricture

of a tube disease.

zation and being associated

with

may not be useful in

gastrointestinal

an open

jejunostomy

endoscopic for

and

tube jejunostomy.

feeding Laparoscopic

require tumours

rationale

patient’s

staging

of

1: 245-249.

instances,

INTRODUCTION

may

is a safe

and the patient’s

specific

foregut

placement

placement

the oncology

Oncology

who

The technique,

tube

standard

in two

adenocarcinoma

or obstructing

laparoscopic

feeding and stage

formula

or mortality.

utilized

advanced

chemoradiation,

metastatic

access

and facilitates

being

and medication.

who

than

morbidity

with

Laparoscopic

to gain enteral

are

or locally

of preoperative

of fluid

is less invasive

placement, without

for delivery

tubes

resectable

(ii) patients

are described.

method

procedure

and

a route

jejunostomy

with

on a protocol

support,

require

jejunostomy

(i) patients

Cancer

therapy

in

cancer only after

that includes laparos-

of staging inserted

laparoscopy, using

jejuno-

laparoscopic

and these tubes are then used for enteral

during

the

jejunostomy

period tubes

of neoadjuvant

therapy.

can also be placed

in

Short Report

246 those

patients

who

have unresectable

require palliation of obstructing We

have developed

placing

a Witzel

videolaparoscopic

disease

the operative

feeding

tube

tube

for using

This report briefly out-

lines the steps involved in laparoscopy-assisted ing jejunostomy

placement

feed-

and describes

results of our first 17 consecutive

urinary

catheter

lnsufflation

technique

jejunostomy

technology.

and

symptoms.

the

patients who under-

went this procedure.

and oral-gastric

of the

plished with a Verres needle A lo-mm

disposable

Surgical

just

below

laparoscope

cavity

(IO mm),

with

and the abdominal

metastatic

implants

disposable

Connecticut)

trocar

the

camera

introduced 5-mm

United States

umbilicus,

and

accom-

or the Hasson cannula.

Norwalk, the

placed.

was

trocar (Surgiport;

Corporation,

placed

tube were

abdominal

attached,

cavity

hepatic

was

was

operating was

explored

for

metastases.

placed

A

just lateral

to

the rectus muscle and 3-cm cephalad to the umbilicus MATERIALS

AND

METHODS

on the left side of the abdomen. used for the irrigation/aspiration

The records went

of 17 consecutive

staging

placement

laparoscopy

from

January

patients

with

who

under-

jejunostomy

tube

to December

1991

were

reviewed.

toneal

washings

dure.

After

induction

of

general

of the proce-

anaesthesia,

a

analysis.

An

of blunt graspers

exploration

the visual

peritoneal on the morning

probe to obtain peri-

cytological

the right for placement After

Patients were admitted

initially addi-

tional 5-mm trocar was placed in a similar location on with abdominal

Technique

for

This was

(Fig. 1).

exploration

washings

was

completed

had been obtained,

was placed in the reverse Trendelenburg rolled to the right to enhance ment

of Treitz.

removed proximal

and

jejunum

with

position and

exposure

of the ligaprobe was

a blunt

can be identified

greater omentum

and transverse

and

the patient

The irrigation/aspiration replaced

to assist

grasper.

The

by retracting

the

colon cephalad

and

exposing the ligament of Treitz. The jejunostomy

tube

(Flexiflo:

was

brought

Ross Laboratories, through

upper quadrant the Seldinger of proximal 3-4

cm

through

jejunum

upper

wall

a peel-away

technique

jejunostomy

Columbus,

the abdominal

Ohio)

in to the left introducer

was then exteriorized

midline

incision

was completed

sutured to the anterior

through a

(Fig. 3). A Witzel

(Fig. 4) and the bowel

abdominal

wall. The abdomi-

nal wall was closed in layers with absorbable and the two remaining

Postoperative

via

(Fig. 2). The tube and a loop

suture,

trocars were removed.

care

Patients were given nothing by mouth on the day of surgery.

Most

patients

hospital that evening tained

their

placement

of a laparoscopy-assisted

exploration

tube jejunostomy.

and

increased guidance

at

20-30

over

the

h-’

next

of the nutritional

and 4-5

Patients initiated

on post-operative

diet was started ml

the

and main-

diet and were

as out-patients

day 1. An elemental strength

from

pain formulations.

preoperative

on tube feedings

discharged

or the next morning

on oral or enteral

resumed

Figure 1. Trocar placement for abdominal

were

at half or fullwas

days

gradually under

support service.

the

Short Report

Figure 2. The jejunostomy

tube is

brought through the abdominal inside a peel-away

wall

inducer.

Figure 3. After identification

of the

ligament

of Trek,

a loop of proxima II

jejunum

is located

and exteriorized

along with the jejunostomy through

a small midline

tube

incision.

Figure 4. The Witzel serosal tunnel is completed to the anterior to wound

and the bowel sutured abdominal

closure.

wall prior

247

Short Report

248

RESULTS

jejunum

could significantly

manipulation The median 47-81

age of the patients was 62 years (range,

years).

Seven

of

patients

were

mal-

degrees.

Enteral

access

was

operative

chemo-

disorder:

to varying

necessary

as an adjunct

therapy

and/or

for palliation

to

radiation

in three.

preoperative

therapy

in 14 patients

Visual staging

and

and washings

While

treating

either This

decreased

tolerance

whom

the procedure

access,

and

operative The

time

line

was of

surgeons became

patients

in

was limited to staging, enteral

central

duration

In

placement,

110 min the

the

(range,

median

36-125

procedure

min).

decreased

more adept at laparoscopic

dures. If other diagnostic

procedures

as

proce-

did not inter-

nutritional

chemotherapy,

status throughout The combined and placement

Patients

are discharged

practice

care,

technological

toward the

advances

the use of minimally

treatment

and

have

diagnosis

ultrasonic

logical procedures. for the diagnosis diseases abdominal timely when

and will

Although

for identifying

true

metastases

are

[4-71.

staging

of

patients

stomach

and pancreas since

involved

early

organ,

peritoneal

revolution

not

with

it became

During

disease.

Direct

laparoscopic

that localization

the need for nasogastric

tube

hyperalimentation.

Unlike a

laparoscopic

jejuno-

to create a Witzel

who

cutaneous

fistula.

component

cancer

serosal

tunnel

should

of the laparoscopic

staging

and

placement

tubes more accurately while

tube

an enterofeed-

procedure.

Laparoscopic feeding

The Witzel

fistula

a jejunostomy

providing

The importance

of enteral

stage the patient with

a means

of maintaining

for enteral adequate

access,

nutritional

stores in the cancer patient will receive even greater as

the

use

of

multimodality

therapy

routine.

radioof the of the (liver), for

the stage of disease

abdominal

feed-

describing

patient

of

of tube

peri-

obtained

use of locoregional

invasiveness

initiation

preoperative

inspection

washings

rapid

placed without a serosal tunnel, developed

becomes

sites of metastases

and

shortly after the procedure

had

attention

adenocarcinoma

1990.

neoadjuvant

an enterocutaneous

One

staging

malignancies.

[IO].

pancreatic

visualized for

gastric

serosal tunnel to prevent

are excellent

has been utilized at our insti-

potential

apparent

prognosis

and

well

js

intra-

in solid organs,

cytology can aid in determining therapy.

poor

studies

Laparoscopy

lining

and the appropriate

a

to change

Several

of gastric

gross disease

report

be a standard

continue

of

tube is now

receiving

stomy, we feel that it is important

ing jejunostomy

unresectable

radiological

graphically

tution

with

previous

of laparoscopic

and

or intravenous

of intra-abdominal

have

present

is especially

toneal

allows

use of laparoscopy

This technological

malignancies

patients

cancer.

the

and invasive radio-

in the field of GI malignancies.

abdominal This

The current

for

diseases.

in the fields of GI

and treatment

surgery.

directed

of various

lithotripsy,

has altered

been

invasive procedures

This has been well demonstrated endoscopy,

in health

to

of preoperative

and the minimal

ings. This abrogates feedings of cost containment

period

in patients

pancreatic

the procedure

era

lead

it is surgery,

[8, 91. It is therefore

procedure

with no morbidity,

present

can

of a feeding jejunostomy

for

In the

malnour-

or treatment-induced

the entire

therapy

DISCUSSION

chemo-

therapy, which often lasts 6-l 2 weeks.

a routine

their desired feeding regimens wihout difficulty.

another

to maintain the patient’s nutritional

first postoperative

to

in a pre-

receiving

depletion

or irradiation

great importance

cancer

is creating

to therapy, whether

vene, tube feedings were successfully initiated on the day. All patients were advanced

of a standard

or both, become

GI toxicity

anorexia.

mortality.

Patients

or radiotherapy, from

operative

or

the incision and

with

the oncologist

malnutrition.

therapy ished

the patient

setting,

for cytology were done in all patients. There was no morbidity

decrease

for placement

operative tube jejunostomy.

17

nourished

necessary

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