Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes
© The Author(s). 2017
Received: 22 September 2016
Accepted: 10 March 2017
Published: 20 March 2017
In recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes.
The medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes.
Fifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days.
Laparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success.
KeywordsLaparoscopic jejunostomy Feeding jejunostomy Tube jejunostomy Staging laparoscopy Oesophagogastric cancer
Staging laparoscopy has emerged as an important staging modality for upper gastrointestinal (UGI) malignancies. It is most useful in detecting and confirming nodal involvement and small liver and peritoneal metastases that can potentially alter the prognosis and treatment strategy from curative to palliative intent [1, 2]. The placement of a feeding jejunostomy tube during staging laparoscopy is often necessary to establish enteral feeding when oral intake is not possible or a gastrointestinal obstruction is expected to occur, such as in the presence of unresectable obstructed tumour or advanced metastatic cancer. Patients with severe sarcopenia will also benefit especially if they are to undergo neoadjuvant chemotherapy for down-staging or palliative chemotherapy. The benefits of a feeding jejunostomy to enable improvement of nutrition in those requiring chemotherapy and maintenance of enteral access during the period of profound gastrointestinal toxicity while on chemotherapy cannot be underestimated.
The first laparoscopic technique of feeding jejunostomy was described by O’Regan et al. in 1990 . The technique underwent modifications with several descriptions and commercially available products that facilitated the insertion of feeding tubes were introduced. However, the use of commercially available product increases the cost of the surgery, making it unfavorable in developing countries where health budget is a concern. Thus, we devised a total laparoscopic technique using a T-tube to overcome this limitation. This review describes our initial experience with laparoscopic feeding jejunostomy with its technical details when used as an adjunct to staging laparoscopy.
A retrospective review of all patients (15 patients) who underwent laparoscopic feeding jejunostomy during staging laparoscopy for UGI malignancy between March 2010 and July 2015 was performed. The indications for feeding jejunostomy were: 1) Metastatic disease with peritoneal nodules or 2) Locally advanced carcinoma requiring neoadjuvant therapy for down-staging. The decision for feeding jejunostomy or palliative gastrojejunostomy bypass procedure in patients with metastatic cancer was based on the degree of tumor infiltration of the stomach wall. Palliative gastrojejunostomy will be the preferred option in patients with gastric outlet obstruction. However, patients with linitis plastica or gastric inlet obstruction; feeding jejunostomy was performed. The data analyzed included demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), types of malignancy, indications for feeding jejunostomy, operative technique, operative time, length of hospitalization and operative outcomes. The study was approved by the hospital ethics committee and Director-General of Health of Malaysia. Preoperative computed tomography (CT) scan of the abdomen and pelvis was the routine method of pre-operative staging. Prophylactic antibiotic was given intravenously during induction of anesthesia. Clear fluid was started via the feeding tube postoperatively on the day of surgery. Enteral milk feeding was started on the first postoperative day, employing a standard protocol outlined in the department. The feed was administered as a continuous infusion commencing at 30 ml/h for 3 h with an hour’s break between feeds. The feeds were gradually increased to 100–150 ml/h as tolerated. Patients were allowed oral free fluids as tolerated and were discharged with out-patient appointments. Patients must have established full enteral feeds and no major tube-related complications. The T-tube remained in-situ until the end of patients’ lifespan or removed when patients were able to tolerate sufficient diet containing solid food or at their request.
Following discharge from the ward, patients were reviewed once every 3 months for the first 2 years, then every 6 months for the following 3 years. There was no loss of patients to follow-up during the study period. Patients or the next of kin were contacted in the event of a missed clinic appointment.
Complications were broadly classified into early (those occurring within 30 days of jejunostomy placement) and late (those occurring ≥30 after the procedure). These complications were either tube-placement related, or feed related (bloating, diarrhoea and abdominal colic). Complications were further categorized as minor (catheter occlusion, catheter dislodgement, pericatheter leakage, tube site infection, and feed intolerance) or major (bleeding requiring blood transfusion, intestinal obstruction, peritonitis, volvulus, aspiration and any potentially life threatening adverse event requiring the need of a surgical or radiologic intervention).
The patients were reviewed by the nutritional support team postoperatively. Tube feeding commenced from postoperative day one via an infusion pump at a rate of 30 ml/h. Feeding was gradually increased over the next 2–3 days. A feeding pump was used during the initial phase of enteral nutrition until bolus feeds were tolerated.
Demographics and surgical outcomes of patients who underwent laparoscopic T-tube feeding jejunostomy
Number of patients
Age (years, mean ± SD)
63.3 ± 7.3
Body mass index
19.8 ± 2.8
Operative time (minutes, mean ± SD)
66.0 ± 7.4
Postoperative hospital stay (days, mean ± SD)
5.6 ± 2.2
Conversion to laparotomy
This study shows that laparoscopic feeding jejunostomy can be performed safely with no significant morbidity as an adjunct to staging laparoscopy. The procedure requires only standard basic laparoscopic instruments such as laparoscopic hook, Maryland forceps and monopolar electrocautery. The use of T-tube is an inexpensive alternative to commercially available feeding tubes.
Since the first description of the use of jejunostomy tube in 1891 by Witzel , a vast majority of patients with UGI malignancies requiring nutritional support have successfully undergone open jejunostomies. However, the open technique is associated with increased operative morbidity and hospital stay . A laparoscopic approach is ideal as it not only confers the advantages of minimally invasive techniques but avoids inflicting an additional surgical scar as one of the port sites can be used as the exit wound for the feeding tube with lower rates of surgical site infection.
There are considerable variations in techniques described in the literature for performing laparoscopic feeding jejunostomy. In general, either the total laparoscopic or laparoscopic-assisted techniques have been employed . The most common technique for total laparoscopic placement of feeding catheter is the Seldinger technique [1, 7, 8]. It is a technique commonly involves a commercial product [9–11], with percutaneous placement of feeding catheter performed after the bowel is secured to the abdominal wall, using a combination of needle, wire, dilator, stent and feeding tubes [1, 7, 8]. Different combination techniques have been described [12, 13]. Laparoscopic-assisted techniques involve exteriorizing the jejunum through a small abdominal incision or one of the trocar openings  to allow extracorporeal enterotomy and placement of the catheter. Total laparoscopic technique is superior as it avoids minilaparotomy incision but has the disadvantage of requiring intracorporeal suturing . Our technique is a total laparoscopic technique that does not requires percutaneous jejunostomy kit. It mimicks the open technique with the initial placement of the feeding tube, followed by the withdrawal of the tube through a left abdominal port site and finally fixation of the jejunum to the abdominal wall via transabdominal sutures.
There are three techniques described to secure the entry of the feeding jejunostomy tube into the jejunum: a purse-string suture, the Stamm inverting style or a Witzel tunnel . We adopt the purse-string suture method as we feel that it is an easier option laparoscopically as compared to the Witzel and Stamm techniques. The Stamm technique, initially described for gastric access and later adopted for enteral access, incorporates both the purse-string suture around the enterotomy site and inverting stitch of jejunal wall around the tube to the overlying peritoneum. It requires some degree of finesse in order to place an inverting stitch laparoscopically through the abdominal wall, a maneuver that requires a pronounced supination-pronation of the wrist to drive the needle through the abdominal wall. The Witzel technique involves creating a short serosal tunnel with imbricating sutures over the tube and along the long axis of the bowel. One study that favour Witzel tunnel indicated that such technique reduces the incidence of severe surgical site infections and the rate of late jejuno-cutaneous fistulation . Performing Stamm and Witzel techniques laparoscopically, though feasible, can be technically challenging and time consuming when done exactly like in the open technique . Taking too much of the jejunum while constructing Witzel tunnel could also lead to luminal obstruction at the catheter insertion site . Dislodgement of the catheter from a Witzel tunnel collapses the tunnel and does not allow easy placement of catheter. On the contrary, a straight passage from the enterotomy to the anterior abdominal wall is important as it gives a straight trajectory that allows easy replacement of a catheter in the event of dislodgement. The rationale of the purse-string sutures is to create a seal around the jejunal catheter. A second purse-string may be over-elaborative or unnecessary. However, we maintain the practice as we did not encounter any case of intraperitoneal leakage of jejunal content. In addition, it is a much simpler procedure than the Stamm technique of additional inverting stitch. Transfascial suturing aligns the jejunum to the parietal peritoneum and minimizes the risk of volvulus.
Different techniques of anchoring the jejunum to the anterior abdominal wall have been described, either in the forms of transfascial sutures (transabdominal sutures [8, 10] or T-fasteners [5, 16]) or intracorporeal sutures [13, 17]. The transabdominal sutures (3–4 in number) are usually placed in a diamond configuration, incorporating the seromuscular layer of the jejunal wall and the anterior abdominal wall . The free ends of the suture are brought out onto the surface of abdomen using a thread gasper and the two threads are tied with the knot secured at the fascial layer . Alternatively, the suture could be tied over bolster placed on the skin to prevent skin damage from the suture [8, 11]. The T-fastener, originally developed for fixation of stomach to the anterior abdomen in laparoscopic gastrostomy, consists of a nylon suture attached to a metal T-bar, is introduced percutaneously and dislodged into the jejunal lumen from the slotted needle by the stylet [5, 16, 18]. Its placement over antimesenteric jejunal wall usually follows a diamond configuration [5, 16]. Our technique differs to the conventional 3–4 sutures diamond or triangular configuration. We believe that 2 sutures suffice in aligning the jejunum against the abdominal wall after the purse-string sutures have secured the tube snugly into the enterotomy.
In terms of outcomes, our initial results demonstrate that the technique of laparoscopic T tube feeding jejunostomy can be performed as an adjunct to staging laparoscopy without any increase in peri-operative morbidity. The main technical challenge encountered during this procedure was the insertion of the T tube into the enterotomy. Prior to insertion, it is important to remove the back wall of the horizontal limbs of the T-tube in order to prevent clogging as well as allowing guide-wire access for tube exchangei. Additionally, we cut the horizontal limbs into two unequal ends. Our insertion technique entails initial widening of the enterotomy using Maryland forceps and inserting the long end first followed by the short end. We feel that the technical dexterity required for tube insertion will be improved once the procedure is performed on a regular basis.
Comparison of selected studies on laparoscopic feeding jejunostomy in cohorts of 10 or more patients
Indication for placement
Operative Techniques (total laparoscopic/laparoscopic aided)
Tube-related complications (Minor/Major)
Feed-related gastrointestinal symptoms
Sangster W et al. 
Total laparoscopic using a 10-French jejunostomy catheter kit
Minor complications (n = 2, 8.7%): superficial skin breakdown around the tube (n = 2). Major complications (n = 1, 4.3%): superficial abscess around the tube requiring I & D. One unrelated death.
No procedure related complications. A valuable addition to the surgeon’s options for obtaining enteral access.
Grondona P et al. 
Part of staging laparoscopy for esophagogastric cancer
Total laparoscopic using a dedicated feeding jejunostomy kit
Minor complications (n = 3, 16.7%): tube dislodged (n = 1), leakage with wound infection (n = 1) & wound infection (n = 1). No major complications.
A safe and reliable technique. A useful adjunct to staging laparoscopy for esophagogastric cancer.
Allen JW et al. 
Total laparoscopic using a 16 French T-tube
Minor complications (n = 4, 11.4%): wound infection (n = 2) & leakage (n = 2) Major complications (n = 1, 2.9%): intractable pain requiring laparotomy
Safe technique with no significant morbidity or mortality
Ben-David K et al. 
Prior to definitive minimally invasive esophagectomy
Total laparoscopic using a 16-French T-tube
Minor complications (n = 15, 9.8%): superficial wound infection (n = 4), dislodgement (n = 2), leak (n = 4) & clogging (n = 5). No major complications.
A feasible and safe technique in one of the largest series of laparoscopic feeding jejunostomy tube for esophageal cancer patients.
Mistry RC et al. 
Total laparoscopic using a 12-French T-tube
Minor complications (n = 1, 5.3%): extraperitoneal leakage of feeds due to a damaged vertical limb of the T-tube.
An easy, inexpensive technique that does not require specialized equipment or feeding tubes.
Senkal M et al. 
Primary or recurrent tumors of the upper gastrointestinal tract
Total laparoscopic using a 9-French jejunostomy catheter kit
Minor complications (n = 7, 8.8%): leakage (n = 2), tube occlusion (n = 3) & dislodgement (n = 2). Major complications (n = 1, 1.3%): abscess at the insertion site requiring drainage.
A safe and effective technique. Does not require special equipment such as T-fasteners, or transabdominal suturing.
Heath EI et al. 
Part of the staging laparoscopy for esophageal cancer
Total laparoscopic using a 10-French jejunostomy tube
Only major complications reported (n = 2, 3.4%): perforation of the small bowel requiring laparotomy and small bowel resection (n = 1) & intraoperative pulmonary oedema secondary to aortic valve stenosis (n = 1).
Reported only two major complications with only one related to the procedure of laparoscopic feeding jejunostomy. Minor complications were not reported.
Hotokezaka M et al. 
Total laparoscopic using an 18-French Silastic duallumen feeding tube
Conversion to open (n = 4, 12.5%). Minor complications (n = 9, 32.1%): dislodgement (n = 3), obstruction (n = 2) & leakage/wound erythema (n = 4). Major complications (n = 3, 10.7%): dislodgement (n = 1) & aspiration pneumonia (n = 2). Death within 30 days (n = 3, 10.7%): aspiration pneumonia and respiratory distress (n = 1) & unrelated death (n = 2).
Four patients (14.2%) had nausea and one (3.6%) abdominal cramp.
Safe procedure. High morbidity is usually related to preexisting disease. Previous abdominal surgery is not necessarily a contraindication.
Jenkinson AD et al. 
Part of the laparoscopic staging for esophagogastric cancer
Total laparoscopic using a 6-French infant feeding catheter (Vygon)
Minor complications (n = 11, 25.6%): dislodgement (n = 5), blockage (n = 4) & connector breakage (n = 2). Major complications (n = 1, 2.3%): Dislodgement requiring laparoscopic replacement.
A safe and simple technique that adds little to the morbidity and cost of managing patients with esophagogastric cancers.
Pili D, et al. 
Patients undergoing major surgery for esophageal cancer
Total laparoscopic using 8- French jejunostomy catheter kit.
Minor complications (n = 3, 12.0%): chronic catheter occlusion (n = 2) & slippage (n = 1). No major complications.
No procedure related morbidity or mortality. A feasible procedure with the use of autoadjustable sutures to overcome the limitation of the laparoscopic handling.
Duh QY et al. 
Various indications (a multicentre study)
Total laparoscopic using jejunostomy catheter kit and T-fasteners.
Conversion to open (n = 3, 8%). Minor complications (n = 6, 16.7%): wound erythema or infection (n = 3) & dislodgement (n = 3). Major complications (n = 3, 8.3%): volvulus (n = 1) & dislodgement (n = 2). Death (n = 4, 11.1%): unrelated to procedure.
A safe and effective technique when done by experienced laparoscopic surgeons. Serious complications are rare.
Young MT et al. 
Various indications with majority for esophagogastric cancer
Total laparoscopic using 10-French jejunostomy catheter kit
No conversion to open surgery. aEarly complications (n = 12, 4.0%): dislodgement (n = 3), clogging (n = 3), intraperitoneal displacement (n = 2), broken tube (n = 1), rectus sheath hematoma (n = 1) & abdominal wall site infection (n = 2). Late complications (n = 26, 8.7%): small bowel obstruction (n = 1), jejunal fistula (n = 11), dislodgement (n = 10) & broken or cogged tube (n = 4). Mortality (n = 1, 0.3%): unrelated to procedure.
A safe and feasible technique. Associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.
Part of the staging laparoscopy for upper gastrointestinal malignancies
Total laparoscopic using 18-French T-tube
Minor complications (n = 7, 46.7%): Skin excoriation around tubing (n = 4) & catheter dislodgement (n = 3). No major complications.
Three patients (20.0%) had feed intolerance.
A safe, cost-effective technique with no procedure related complications.
Feeding jejunostomy is a simple procedure yet an important adjunct to staging laparoscopy. With the aim of achieving early enteral feeding and a reduction in postoperative morbidity, any complications arising from the procedure will jeopardize its benefits as it will incur additional costs and delay subsequent oncologic treatment. Meticulous attention to tube placement technique remains a sine qua non to limit complication rates. Dislodgement of the tube can be avoided by attention paid to the technique of securing and confirming catheter placement prior to usage . Appropriate fixation of jejunum to the parietal peritoneum avoids migration of tube to the abdominal cavity , and the occurrence of small bowel volvulus or obstruction at the jejunostomy site [5, 23]. Our technique of double purse-string suturing ensures that the tube fits snugly in the small bowel, eliminating the risk of leakage of jejunal content. In addition, the T configuration of the tube prevents the risk of accidental tube dislodgement unless the tube is forcefully jerked. Transfascial suturing aligns the jejunum to the parietal peritoneum, preventing the bowel from falling away from the anterior abdominal wall. Our technique may appear to be more demanding than those described in the literature but it can be mastered from repeated practice. The time invested in perfecting the technique is rewarded with a favorable outcome as reflected in our series showing no leak or dislodgement. Prior to initiating enteral feeding, some authors perform a contrast study a day after the procedure prior to confirm the patency and intraluminal position of the tube [12, 23]. However, we typically flush the feeding catheter with normal saline to check its position and for any leak under laparoscopic visualization intra-operatively.
A T-tube has several advantages over other types of tubes. Firstly, the T configuration of the tubing is resistant to accidental dislodgement of the tube, reducing the risk of peritonitis. Secondly, the soft latex T-tube has less risk of intestinal perforation as compared to stiffer jejunostomy tubes and encourages the early formation of a fistulous tract . This enables safe and easy replacement in the event of dislodgement . In addition, a T-tube obviates the risk of bowel obstruction as it is generally smaller than other types of tube and it does not require an insufflated balloon to maintain its position in the bowel lumen. The insertion of the tube under direct vision and confirmation of position and non-leakage at the end of procedure eliminates the need for radiological confirmation. Balloon devices have been known to cause bowel obstruction due to overfilling of the balloon which can also cause pressure necrosis of the bowel wall.
Feeding intolerance is demonstrated when the patient developed feeding-related abdominal symptoms such as abdominal distension and diarrhea . The degree of enteral tolerance varies in different studies and the frequency ranges from 5 to 35% . However, it is often self-limited and can be corrected by adjusting the infusion rate and concentration of the feed or temporary cessation of feeding . Three patients in our series had feed intolerance and did not achieve the target calorie and protein requirements within three days but the abdominal distension was self-limiting and resolved.
In conclusion, our experience with laparoscopic feeding jejunostomy as an adjunct to staging laparoscopy demonstrates that it is a safe and feasible technique. Our inexpensive modification using a T-tube is safe with no immediate post-operative complications or mortality resulting from the procedure. It enables nutritional supplementation for patients with metastatic UGI malignancies as well as patients who require neoadjuvant therapy to downstage their tumours. The overall incidence of complications in our series may seem unacceptably high but the complications were all minor and were managed expectantly.
American society of anesthesiologists
Body mass index
Tumour nodes metastasis.
The authors thank the Director General of Health, Malaysia, for permission to publish this paper.
Availability of data and materials
Data will not be shared due to rules and regulations in Malaysia.
SLS, HAM: Study conception and design. NKM: Acquisition of data. SLS, HAM: Analysis and interpretation of data. SLS: Drafting of manuscript. HAM, CMW, MN: Critical revision of manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interest.
Consent for publication
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of the Sarawak General Hospital.
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