Indications

1. •Usually postoperative feeding where there is a known oesophageal or gastric leak, a suspected leak or a high chance of leak.
   

2. •Swallowing dysfunction/discoordination post surgery.
   

3. •Oesophageal obstruction unable to be relieved surgically or otherwise (Note that aspiration will still occur. If the patient is terminal the main indication for jejunostomy is to allow them home. It may not lead to a more comfortable death)
   

4. •Nutrition during neoadjuvant or adjuvant therapy
   

Anaesthetic

1. •General, though local is technically feasible
   

2. •Single lumen ETT
   

3. •Epidural not required
   

4. •administer local Marcaine 0.25% into wound at end of procedure
   

Incision

1. •Limited upper midline laparotomy
   

2. •(though may be inserted via almost any upper abdominal incision e.g. laparoscopy, full laparotomy, thoracolaparotomy, limited transverse rectus cutting laparotomy etc)
   

Choosing and preparing a canula

1. •12 French Foley Catheter (male is longer) is the easiest cannula to find in an emergency operating theatre (though specific commercially made cannulae are available.)
   

2. •A larger Foley can be used and will allow thicker feeds and drugs, but fashioning a Witzel tunnel around it may compromise the lumen of the jejunum causing high bowel obstruction.
   

3. •Cutting off the tip to produce a small hole will allow change of a blocked tube over a guidewire at a later date.
   

4. •K McManus prefers the balloon to be deflated and recommends that the balloon channel be cut off so the balloon cannot be inflated.
   

Procedure

1. •identify skin site (a few centimetres lateral to the incision, usually to the left in the left upper quadrant.
   

2. •place Roberts forceps through peritoneum, rectus muscle and fatto tent up the skin from within. Cut onto forceps with scalpel.
   

3. •grasp catheter tip with Roberts and draw into peritoneum.
   

4. •identify transverse colon with taenia coli, elevate
   

5. •find duodeno-jejunal junction at ligament of trietz
   

6. •work distally 30cm an hold jejunal site with a Babcock forceps proximally and distally
   

7. •place two pursestring sutures (2/0 Vicryl) at site, one within the other with the tails on opposite sites of the selected site
   

8. •use mosquito forceps to pick up the serosa at the selected site and gently apply coagulation cautery. Bluntly dissect through the cauterised serosa and pick up each layer in turn, using a cautery/blunt dissection technique till into the jejunal lumen.
   

9. •pass the tip of the cannula into the jejunum and feed the loops over it as far as possible
   

10. •K McManus prefers not to inflate the balloon but others will inflate for 24 hours
    

11. •tighten the purse-strings - inner first. Try to invaginate the first as the second is tightened.
    

12. •create a 2.54 cm Witzel tunnel by bringing the serosa together over the cannula. Be cautious not to wander further and further aross the lumen with successive sutures
    

13. •pulling gently on the portion of cannula that is outside the skin, bring the jejunostomy site to the anterior abdominal wall
    

14. •suture the jejunostomy site to the peritoneum of the anterior abdominal - usually four interrupted sutures around the site using 2/0 Vicryl
    

15. •suture the jejunostomy cannula to the skin with heavy silk (commercial skin fasteners are available but usually not in an emergency theatre - ask the stoma nurse to apply one the next day)
    

16. •flush with 20cc of 5% dextrose
    

17. •close the laparotomy is standard fashion. (As many of these patients are cachectic I frequently close with interruted Ethibond as I feel it reduces the chance of dehiscence if one suture breaks.)
    

Postoperative care

1. •(K McManus) flush with 20cc 5% dextrose per hour for 24 hours (if it is leaking or blocked this should be evident by 24 hours)
   

2. •Thereafter start routine feeding regime
   

3. •(A Graham) prefers to spiggot the tube for a number of days till a contrast injection has demonstrated the tube is in the jejunal lumen and there is passage of dye into the colon.
   

4. •flush with saline routinely twice per day and after each drug or feed administration (for some drugs there are specific instructions)
   

If it blocks

1. •prevent blockage by regular flushing as above
   

2. •flushing with sodium bicarbonate or pancreazymin may dissolve a blockage
   

3. •if the above are unsuccessful and the jejunostomy has been in place for 5 days at least, it is possible to change it. Ideally this should be done in Xray to check the position with an injection of dye. It is often possible to pass a guidewire through the obstructing food debris and out the tip of the cannula, remove the cannula and pass a new one over the wire.
   

4. •If a jejunostomy tube falls out, replace it immediately. It should p[ass relatively easily. Check with contrast injection. Do not delay re-insertion as the granulation track will close over in under an hour