Overview
Definition:
A feeding jejunostomy is a surgically created opening into the jejunum for the purpose of enteral nutrition
The Witzel technique is a specific method for its creation, involving intussusception of a loop of jejunum into a larger serosal tunnel.
Epidemiology:
The incidence varies based on the types of gastrointestinal surgeries performed, particularly those involving the stomach or esophagus
It is commonly employed in patients requiring long-term nutritional support post-operatively or in cases of inability to tolerate oral or gastric feeding.
Clinical Significance:
Provides a route for nutritional support in patients who cannot adequately feed orally or via nasogastric/gastric tubes
Essential for maintaining nutritional status, promoting healing, and preventing complications like malnutrition and sarcopenia in critically ill surgical patients
Allows for early initiation of enteral feeding, which is superior to parenteral nutrition in many scenarios.
Indications
Indications For Placement:
Failure of oral intake due to oropharyngeal dysphagia
Gastric outlet obstruction not amenable to immediate surgical correction
Short bowel syndrome with inadequate oral intake
Pancreatitis requiring bowel rest
Prolonged intubation
Post-esophagectomy or gastric resection requiring long-term enteral feeding
Patients requiring chemotherapy or radiotherapy affecting oral intake
Malnutrition in patients unable to tolerate gastric feeding.
Contraindications:
Peritonitis
Extensive intra-abdominal adhesions precluding safe manipulation of the jejunum
Complete bowel obstruction distal to the jejunum
Uncorrected coagulopathy
Hemodynamic instability
Extensive mesenteric ischemia.
Timing Of Placement:
Can be performed at the time of other abdominal surgery (e.g., gastrectomy, Whipple procedure) or as a standalone procedure
Early placement in the perioperative period is often preferred for prompt nutritional support.
Preoperative Preparation
Patient Assessment:
Nutritional status assessment, including serum albumin, prealbumin, and body mass index
Assessment of comorbidities
Evaluation of coagulation profile.
Bowel Preparation:
Routine bowel preparation may be performed, although it is often less critical for jejunostomy compared to colonic surgery
Antibiotic prophylaxis is standard for any surgical procedure.
Informed Consent:
Discussion of the procedure, risks (bleeding, infection, bowel leak, fistula, obstruction), benefits, and alternatives (parenteral nutrition, nasogastric feeding) with the patient or their legal representative.
Procedure Steps Witzel Technique
Surgical Approach:
Typically performed via a laparotomy or laparoscopically
Laparoscopic approach offers advantages in terms of smaller incisions and faster recovery.
Jejunum Selection:
A loop of jejunum, usually 15-20 cm distal to the ligament of Treitz, is identified and mobilized
Care is taken to avoid tension on the mesentery.
Creating The Serosal Tunnel:
A 3-4 cm serosal tunnel is created by dissecting the mesentery of the selected jejunal loop
This helps to anchor the tube and reduce the risk of leakage.
Tube Insertion:
A feeding tube (e.g., 10-14 Fr silicone tube) is inserted into the lumen of the jejunum after creating a small enterotomy within the serosal tunnel
The tube is advanced distally.
Mucosal Closure:
The enterotomy site is closed with a single layer of absorbable suture (e.g., 3-0 or 4-0 PDS) in a continuous or interrupted fashion.
Intussusception:
The jejunal loop containing the tube is then intussuscepted into the serosal tunnel, creating a valvular mechanism that further secures the tube and prevents reflux and dislodgement.
Tube Exteriorization:
The feeding tube is brought out through a separate stab incision in the abdominal wall, typically in the left upper quadrant
The abdominal wall layers are approximated around the tube.
Abdominal Closure:
The abdominal incision is closed in layers
The feeding tube is secured to the skin with sutures or a secure dressing.
Postoperative Care
Initial Management:
Pain management
Intravenous fluid resuscitation
Monitoring of vital signs and urine output
NPO status until bowel function returns.
Feeding Initiation:
Feeding is typically initiated 24-48 hours postoperatively, starting with slow infusion of water or dilute formula
The rate and concentration are gradually advanced as tolerated
Initial rate of 10-20 ml/hr, advancing by 10-20 ml/hr every 8-12 hours.
Tube Care:
Regular flushing of the tube with water (e.g., 30 ml every 4-6 hours) to prevent occlusion
Site care to prevent skin breakdown and infection
Monitoring for leakage or dislodgement.
Nutritional Monitoring:
Regular assessment of nutritional status, including weight, intake, and laboratory parameters
Adjustment of feeding regimen as needed to meet caloric and protein requirements.
Ambulation:
Early ambulation is encouraged to prevent venous thromboembolism and promote recovery.
Complications
Early Complications:
Bleeding from the enterotomy site
Wound infection
Bowel leak at the enterotomy or along the serosal tunnel
Tube dislodgement
Post-operative ileus
Gastroparesis
Small bowel obstruction due to adhesions or kinking.
Late Complications:
Tube occlusion by formula or food debris
Diarrhea or constipation
Dumping syndrome (rapid gastric emptying)
Malabsorption
Jejunal obstruction
Stomal stenosis
Enterocutaneous fistula
Peritonitis from tube perforation or severe leak.
Prevention Strategies:
Meticulous surgical technique to ensure adequate serosal tunnel length and secure closure of the enterotomy
Careful selection of jejunal loop to avoid tension
Secure tube fixation
Gradual advancement of feeding rates
Regular tube flushing
Prompt recognition and management of any signs of infection or leakage.
Key Points
Exam Focus:
Witzel technique involves intussusception of jejunum into serosal tunnel
Indications include need for long-term enteral nutrition
Complications like tube occlusion and bowel leak are common
Laparoscopic approach is favored.
Clinical Pearls:
Always select jejunum distal to the ligament of Treitz
Ensure adequate length for the serosal tunnel
Secure the tube well to the skin to prevent dislodgement
Start feeding slowly and advance gradually.
Common Mistakes:
Inadequate serosal tunnel length leading to leakage
Not securing the tube adequately
Initiating feeding too aggressively
Failing to flush the tube regularly, leading to occlusion
Misinterpreting symptoms of dumping syndrome.