Keyur Bhatt1, Dhaval Mangukiya1, Pankaj Desai1, Krishna Parekh2
1Department of GI & Minimal Access Surgery, 2Department of Clinical Research, SIDS Hospital & Research centre, Surat, India.
Dr Keyur Bhatt
Feeding jejunostomy (FJ) is an adjuvant therapy that provides nutritional support through the enteral route by situating a tube in the lumen of the jejunum. It is an excellent, safe and effective surgical procedure following major gastrointestinal surgery to maintain enteral feeding. Enteral feeding is more physiological and cost effective than parenteral nutrition. However, it is not totally free from complications. The most commonly report complications are local skin infections, gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal blotting) and metabolic abnormalities. Rarely reportedcomplications of an FJ are aspiration pneumonia, peritonitis and small bowl necrosis.1,2 We report an unusual complication in the form of knotting of a feeding jejunostomy tube.
A 25-year-old female with corrosive ingestion underwent reconstructive surgery and FJ in October 2017. One and a half months later, she presented with complaints of inability to feed through the FJ tube. On examination, the outer part of the FJ tube was found to be normal but even after applying force, water could not be instilled. Hence, an abdominal X-ray (Figure1(A)) and a gastrograffin study (Figure 1(B)) were done which revealed knotting and kinking of the FJ tube. On the same day, laparotomy was performed to remove the tube (Figure 1(C,D)) and a new FJ was created. The patient is on follow-up onan outpatient basis without any further issues.
During the past three decades, FJ has become increasingly popular following any major gastrointestinal surgery, in oropharyngeal cancer, and in patients with bulbar palsy. Complications have been reported in 2%-12% of cases in literature.1 The reported complications include mechanical, local, metabolic and gastrointestinal problems.2 Of these complications, knotting of the FJ tube is extremely rare.Tilldate, only three cases have been reported.3,4,5
The proposed mechanism for knotting of the FJ tube is a reverse direction of tube placement. In such a scenario, each time feedsare given, the tube is forced to go in the forward direction of peristalsis. In the resting position because of broad-based technique of FJ, it will get aligned in a proximal direction leading to intra-luminal knotting. Knotting of the FJ tube may be prevented by performing FJ in a proper broad-based manner (Wetzel) with the direction of the tubedistally or towards the ileum and taking care that the direction of FJ tube is with the direction of peristalsis (distally or towards the ileum). Although knot formation is a relatively complication, it could require another surgery to resolve the problem. Moreover, our case highlights the fact that FJ tube placement is not a simple and risk-free procedure. Often, during surgical procedure, the placement of the FJ tube and abdominal closure is allocated to resident doctors after a tiring long surgery. Care should be taken in every case to prevent such complications and each FJ tube placement should be monitored.
- Carucci LR, Levine MS, Rubesin SE, Laufer I, Assad S, Herlinger H. Evaluation of Patients with Jejunostomy Tubes: Imaging Findings. Radiology. 2002;223:241-7.
- Boukerrouche A. Complications Associated with Enteral Nutrition Using Tube Jejunostomy after Esophageal Reconstruction. Journal of Gastrointestinal & Digestive System. 2015;05(01).
- Pandey CK, Singh N, Dash NR, Saxena R, Singh PK. Migration and spontaneous knotting of feeding jejunostomy tube: an unusual complication. Clinical Intensive Care. 2011;13:39-41.
- Jwo SC. Removal of a self-knotted feeding jejunostomy tube in a patient with tongue base cancer. Int J Oral Maxillofac Surg. 2010;39:922-4.
- Guo-Shiou Liao, Huan-Fa Hsieh, Meng-Hang Wu, Teng-Wei Chen, Jyh-Cherng Yu, Liu Y-C. Knot formation in the feeding jejunostomy tube: A case report and review of the literature. World J Gastroenterology. 2007;13: 973-4.